calendar of events 2006 - mso-hns(c)non-pneumatization of the mastoid in very young children,...
TRANSCRIPT
Volume 1, Issue 1
MSO-HNS Newsletter Page 11
Dato’ Dr Gurdeep Singh Mann,
more fond ly known as the
‘Merdeka Boy’ by those close to
him, was born on Independence
Day, 1957. He obtained his
post-g r a d u a t e q u a l i f i c a t i o n
i n ORL-HNS from Universiti
Kebangsaan Malaysia. He has
served as Head of Department
of ENT, Hospital Ipoh, for the
past 16 years. In addition to his
admin is t ra t i ve work , he i s
act ively involved in c l in ical
THE PRESIDENT ELECT
practice, teaching and research.
He has held various positions in
professional bodies such as the
MSO-HNS, Malaysian Medical
Association and the Malaysian
Society of Allergy and Immuno-
logy. He i s a lso an ac t i ve
sportsman with a particular
love for hockey and golf. He is
married to Datin Mungit Kaur
and has three grown-up sons,
of which two are currently in
medical college.
Paediatric Otolaryngology:Where Paediatricians Talk To ENT SurgeonsHilton Hotel Petaling Jaya8th of April 2006, 2.30 pm to 7.00 pm
5th Rhinoseptoplasty & Aesthetic Surgery WorkshopHospital University Kebangsaan Malaysia (HUKM)9-10 April 2006
26th Malaysian Society of Otorhinolaryngologists -Head and Neck Surgeons (MSO-HNS)Berjaya Langkawi Beach Resort & Spa Resort,Langkawi Island, Kedah, MalaysiaAGM 26-28 May 2006
1st Neuro-Otology Course & 26th TemporalBone Dissection WorkshopHospital UKM, Cheras, Kuala Lumpur4th-8th September 2006
2nd UPM-UMMC FESS CourseDetails to be announced
CALENDAR OF EVENTS 2006
Volume 1, Issue 1
Workshops on various audio-
logical tests were well received
by the audience. Of course the
interesting areas of discussion
were the latest technology in
auditory rehabilitation including
cochlear implants and bone
anchored hearing aids (BAHA).
The second day deal t wi th
topics related to vertigo and
neuro-otology.
Together with this workshop
a s y m p o s i u m o n v e r t i g o
management was he ld fo r
genera l p rac t i one rs aga in
attracting a group of about 40
genera l p rac t i t i oners f rom
around the Klang Valley. Basic
t o p i c s i n v e r t i g o a n d i t s
assoc ia ted p rob lems were
discussed. A hands-on demo
was conducted by Dr. Niramon
showing the various techniques
employed in deal ing with a
patient with BPPV.
The course was conducted in
Westin Hotel in Bukit Bintang
on the 25th and 26th of February
2006 with invited faculty from
the Philippines, Dr. Norberto
M a n t i n e z a n d A s s o c i a t e
Professor Dr. Niramon from
Thai land. Speakers loca l ly
i n c l u d e d D r. K u l j i t S i n g h ,
Professor Dr. Din Suhaimi, As-
sociate Professor Dr. Prepageran,
Professor Dr. Lokman Saim, Dr.
Long Chin-Wan and Dr. Asma
Abdullah. The participation was
very encouraging with almost
80 people majority of which were
postgraduate students in Oto-
rhinolaryngology as well as
both private and government
ENT surgeons. Topics covered
included subjects related to the
auditory and vestibular system.
MSO-HNS Newsletter Page 13
AUDIOLOGY AND VESTIBULAR WORKSHOP
2006 AND OTOLOGY REVIEW
The participation
was very
encouraging
with almost 80
people, the majority
of which were
postgraduate
students in
Otohinolaryngology
as well as both
private and
government
ENT surgeons.
Dr. Jeevanan Jahendran
Exco MSO-HNS
Dr. Niramon demonstrating techniques on managing BPPV patientsduring the hands-on demonstration
Volume 1, Issue 1
RESEARCH ACTIVITIES IN LOCAL
INSTITUTIONS FOR 2005-2006
A Serial Evaluation of the Effects
of Gamat on the Healing Process
of Tympanic Membrane Perforations
in Guinea Pigs.
A Study of Hearing Disorder and
Ear Disease in Kelantan and
Terengganu.
The Effect of Minimal Hearing
Loss on Academic Schoo l
Performance of Primary School
Children in Kuala Terengganu.
Health Related Quality of Life
Assessment in Treated Head
and Neck Cancer Pa t ien ts
Cephalometric Assessment in
Snorers and Non Snorers in
Children.
Brush Cytology in Comparison
with Histopathological Examina-
tion in Nasal Tumours.
UPM
Multiplex PCR of EBV DNA in the
detection of recurrent and residual
nasopharyngeal cancer (MAKNA
Cancer Research Award Grant).
Presence of house dust mites in
the ear wax of patients with otitis
externa.
Desloratadine in patients with
persistent Allergic Rhinitis.
Quality of Life Reduction with
persistent Allergic Rhinitis.
Mental and Emotional Changes
with Persistent Allergic Rhinitis.
Ophtalmological Symptoms in
Patients with Persistent Allergic
Rhinitis.
Epidemiology of Allergic Rhinitis in
Malaysia.
Hospital Ipoh
Review of Salivary Gland Surger-
ies 2002 – 2004.
Endoscopic Assisted Transseptal
Transphenoidal Hypophysectomy
Review of Deep Neck Abscesses
2002 – 2004.
Review of Myringoplaties 2004.
Outcome and Hearing Gain.
Voca l Rehab i l i t a t ion Pos t -
Laryngectomy.
Anatomic Variation of Paranasal
Sinuses based on CT scans.
Magnesium therapy for sudden
sensorineural hearing loss.
Success of speech therapy for
vocal cord nodules.
Cisplatin induced ototoxicity in
NPC patients.
BSER among high-risk groups.
Private Institutions
Mr. SP Palaniappan (Glean-
eagles Medical Centre, Penang)
Benef ic ia l e f fec ts o f Z Net
(permethrin impregnated sheets
for the mattress and pillows) to
control house dust mite induced
allergic rhinitis and asthma.
UKM
Efficacy of Amphotericin B nasal
irrigation in chronic rhinosinusitis.
Double blind placebo controlled
study of the effects of probiotics
(lactobacillus parasei 33) on
allergic rhinitis patients in HUKM.
Paediatr ic coblat ion versus
conventional tonsillectomy. A
randomized single blind study
Ultrasound guided Botulinum toxin
A injection in a drooling patient.
Radiofrequency tissue volume
reduction of soft palate in snoring
Distortion product otoacoustic
emission and contralateral sup-
pression of distortion product
otoacoustic emission in tinnitus
A cross sect ional s tudy of
nasal anatomic var iat ion in
chronics inusitis patients requiring
functional ESS. The efficacy of
topical mitomycin to prevent
adhesion formation post ESS.
Retrospective review on the
incidence of middle ear effusion
in c lef t palate chi ldren and
management outcome in HUKM.
Identification of digenic mutation
of GJB 2 and GJB 6 among school
children.
USM
Study on Prevalence of OSAS in
Children with Adenotonsil lar
Pathology in HUSM – A Pilot Study
In Vitro Study of Tea Tree Oil Effect
on Tissue Growth and Common
Microorganism in Chronic Sup-
purative Otitis Media.
The Comparative Value of Frozen
Section Microscopy and Fine
Needle Aspiration Cytology in
Thyroid Nodules in Predicting
Malignancies.
Evaluation of Nasal Cavity Geo-
metry Using Acoustic Rhinometry:
A Cross-sectional Study Among
Normal Subjects at Hospital USM.
The Accuracy of Sterolithographic
Model of Sinonasal Anatomy
Compared to CT scan and Subject
Measurement.
In Vivo Study of Sea Coral Graft
in Rabbits.
MSO-HNS Newsletter Page 15
Research Activities
in Local
Institutions for
2005-2006
Volume 1, Issue 1
SURGICAL ISSUES IN COCHLEAR
IMPLANTATION IN VERY YOUNG
CHILDREN AND CHILDREN WITH
INNER EAR ABNORMALITIES
Lokman Saim
MD (UKM), FRCS (Edin.),
MS (ORL-HNS) UKM Professor,
Department of Otorhinolaryn-
gology, Universiti Kebangsaan
Malaysia
In the beginning only profoundly
dea f adu l t s w i t h acqu i red
deafness a f te r deve lop ing
speech and language skil ls
were considered for cochlear
implantation. Nowadays cochlear
implants have proven to be
effective and reliable not only in
the postlingually deaf adults, but
also in congenitally deaf and
prelingually deaf children. Due
to the increasing experience
and improvement of implant
technology, the selection criteria
has been further broadened.
Amongst the main extensions are
implantation in the very young
children below the age of two
implantation in patients with
inner ear abnormalities. Both
condi t ions were prev ious ly
considered as contrain-dications
for cochlear implantation. In both
condi t ion the surgeon may
encounter difficulties in electrode
insertion and other intra and
postoperative surgical problems.
Generally in prelingual deafness,
the conditions for successful
cochlear implantation become
more unfavorable with increasing
age of the child. In majority of
cases, these prelingual deaf
children are implanted at age
between 2 to 4 years. Clinical
experience indicates that a
child suffering from congenital
hearing loss will most likely have
normal or near normal speech and
Page 16
“In the beginning
only profoundly deaf
adults with acquired
deafness after
developing speech
and language skills
were considered
for cochlear
implantation”
MSO-HNS Newsletter
to defer surgery in cases of
acute otitis media and otitis
media with effusion. Perfor-
ming a cochleostomy in the
presence of effusion risks
introducing bacteria into the
cochlear caus ing labyrinthi
tis and meningitis.
( c ) Non-pneumatization of
the mastoid
In very young children, pneuma-
tization of the mastoid bone is
still incomplete. Most areas of
the mas toid are bone marrow
spaces. The surgeon may
encounter troublesome bleed-
ing during cortical mastoidec
tomy. However this can be
adequately controlled using
the diamond burrs or appli-
cation of bone wax.
(d ) Relatively small size of
the mastoid and middle ear
The size of the middle ear and
mastoid is relatively smaller
in very young children. There-
fore the space for posterior
tympanotomy is limited. A full
range of smaller size burrs
will be helpful.
(e ) Facial nerve injury
In very young children, the
vertical segment of facial
nerve transverses the mas
toid bone more superficially.
Therefore it is more prone to
injury during mastoidectomy
and posterior tympanotomy.
In inexperienced hands, use
of the facial nerve monitor
is advised.
language acquisition if implanted
before the age of four. As such
itwould be ideal if implantation can
be performed as soon as the
diagnosis is confirmed and other
audiological conditions fulfilled.
With increasing experience and
availability of better audiological
tests, th is can certa in ly be
achieved before the age of two
years. This is happening in
hospitals that implement the
policy of universal newborn
hearing screening. Besides the
problem related to anesthesia
and o ther genera l medica l
challenges in surgery in very
young children, special problems
related to cochlear implant
surgery includes:
(a ) Thin skull bone at the site
for receiver stimulator bed
In children below 2 years the
thickness of skull at the site
may be only 2 mm or less.
Thus the whole thick ness
of bone has to be removed
exposing the dura for a very
thin island of bone at the center.
This allows the dura to be
pushed slightly downwards to
accommodate the receiver
stimulator. Care ought to be
taken during the drilling to
prevent tear of the dura and
CSF leak.
(b ) Otitis media
The probability of otitis media
during implantation is higher
in very young children. There-
fore preoperative evaluation
to exclude otitis media is im
portant. The author prefers
Volume 1, Issue 1
( f ) Thin scalp
The receiver stimulator when
placed beneath the scalp in
very young children may be
felt as a bulge and therefore
may be at a higher risk of in
jury or damage. The inci dence
of extrusion is not expected
to be much higher compared
to older children or adults.
IMPLANTATIONIN
PATIENTS WITH INNER
EAR ABNOR-MALITIES
At surgery the surgeon is to place
the electrode array into the scala
tympani of the basal turn and
insert the electrode coil as much
as possible towards the apical
turn. This is usually achieved with
ease in the majority of cases when
the structure of the cochlear is
normal. There are nevertheless,
some ears with abnormalities
of the cochlear that can make
insertion of the electrode array
more challenging.
Acquired abnormality –
Osteogenesis of the
cochlear
T h e c o m m o n e s t c a u s e o f
os teogenes is labyr in th i t i s
ossificans following meningitis.
The usual route of entry of the
organism is along the cochlear
aqueduct. Therefore the most
common s i te o f new bone
formation is the scala tympani
close to the round window. It will
progress further down the scala
tympani with time.
SURGICAL SOLUTIONS
Scala tympani insertion: In osteo-
genesis it is sometimes still
possible to clear new bone from
the round window area if the new
bone has not extended around the
hook of the basal turn using the
microdrill. In these cases it may
be possible to insert at least 15
electrodes through the scala
tympani.
Scala vestibuli insertion
To enter the scale vestibuli, it
is necessary to obtain a clear
view of the stapes by extend-
ing the posterior tympanotomy
superiorly. The crura of the
stapes is then divided. The
surgeon can use a microdrill
to perform the cochleostomy
to insert the electrodes.
Use of Nucleus Double
Electrode Array
Several surgical techniques have
been prescribed for cochlear
implantation in the completely
ossified cochlea. Most of them
are based on the pr inc ip le
of intracochlear positioning of
several electrodes. This involves
drilling out the new bone from
the basal turn of scala tympani
and insertion of a limited number
of electrodes. Cochlear Ltd deve-
loped a new spl i t electrode
array to enable the placement of
all active electrodes into the
cochlea. The first array which is
placed at the lower basal turn
has 11 active electrodes while
the second array is placed in
the second turn of the cochlea
with 10 active electrodes. The
double array provides additional
treatment modalit ies for the
ossified cochlea.
Congenital abnormalities
of the cochlea
The arrest of maturation during
one of the s tages of inner
ear embryogenesis leads to
various morphologic patterns.
The spect rum of inner ear
mal fo rmat ions may ex tend
from mild abnormalities of the
semicircular canals to complete
labyrinthine aplasia (Michel
deformity). The most oftenen-
countered inner ear anomaly
suitable for cochlear implanta-
tions is the Mondini deformity.
This malformation was described
by Car lo Mond in i and was
characterized by a cochlea
shor tened to one and ha l f
turns and lacking a complete
intercalary septum. In reality
There can be complete lack
development of the otocysts so
that only a single cavity is present
called the common cavity. All
these abnormal i t ies can be
predicted by high resolution CT
scans preoperatively. The author
has also encountered 2 cases of
anatomic abnormality of the basal
turn which makes it difficult to
identify the round window and
promontory. Insertion in Mondini
deformity and Common Cavity
Abnormalities. In Mondini abnor-
mality, if over one and a half turns
of the cochlea exist, there is little
difficulty inserting the cochlear
implant electrodes in the usual
manner. In common cavity abnormal-
ities, the cochleostomy is created
at the most prominent area of
the bulge of the common cavity.
Co chlear implantation in Mondini
deformity of common cavity may
result in perilymph gusher which
is actually CSF flowing into the
cochlear cavity via a patent
cochlear aqueduct or via the
internal auditory canal. This can
be managed with a tight fitting
electrode array at the electrode
entry point and packing the area
with muscle or fibrous tissue.
MSO-HNS ACTIVITIES 2005-2006
JanuaryAnnual ENT Health Camp held on the 15th of January2005 in Kuala Selangor.
April3rd KL Rhinoplasty and Aesthetic Course & Live SurgeryDemonstration, 29-30 April 2005, UKM, Kuala Lumpur.
MayMSO-HNS AGM: in Putrajaya.
AugustUPM-UMMC 1st FESS Course, 13-14 August 2005,UPM/UMMC.
SeptemberOtology, Neurotology & Skull Base Update and BoneAnchored Hearing Aid Workshop, 8-9 September 2005in UMMC.
NovemberThyroid Surgery Updates for ENT Surgeons, 20th
November 2005, KL Hilton.
DecemberAsean Research Symposium on Rhinology, 30November- 3 December 2005, KL Hilton.
January 2006Langkawi International Temporal Bone CourseAwana Porto Malai, Langkawi18-20 January 2006
March 20062nd NUH-HUN Otolaryngology Head & NeckConferenceNational University Hospital, Singapore21-24 March 2006
ORL-HNS Scientific Meeting 2006Renaissance Hotel, Kota Bahru25 March 2006
Kem Cakna Kesihatan Telinga Hidung Dan TekakPulau Redang, Terengganu31 March – 2 April 2006
MSO-HNS Newsletter Page 17
Volume 1, Issue 1
Page 18 MSO-HNS Newsletter
THYROID SYMPOSIUM FOR ENT SURGEONS
it is quite clear that more ENT
surgeons are entering the realm
of thyroid surgery. Participation
was truly encouraging with more
than 70 participants including
post-graduate students, young
surgeons and senior surgeons
as well. Good lectures ranging
from surgery in benign thyroid
disease, to managing neck
diseases in malignant thyroid
disease, complications in thyroid
surgerys well as thyroplasty and
laser cordectomy ware presented.
The finale was the comments
from the panel of experts whose
arguments definitely raised a
few eyebrows in the audience. The
debate as to who should do thyroid
surgery is still going on, but the
general consensus was if you are
trained for it then do it. Otherwise
let the experts handle it. On the
whole a well organized course
by Dr. Kuljit Singh and we look
forward to future courses in thyroid
diseases and surgery.
The participants attentively listening (must be interesting from the looksof it) to the lectures presented
Dr. Jeevanan Jahendran
Exco MSO-HNS
HEALTH CAMP AT PULAU REDANGDr. Jeevanan Jahendran
Exco MSO-HNS
a trip by boat to the various
surrounding islands where we
had great fun with snorkeling.
Though the deep water in certain
places got a little too scary for
some of us. After a wonderful
BBQ that night followed by a
lucky draw, we were all too tired
for anything else but the bed. The
next day before our final farewell,
a trip to the Marine park was
organized and it was good fun
with loads of fishes to be seen
whi le snorkel ing and some
friendly enough to actually take
food from your hands.
Congratulations to Dr. Amran
and his team for organizing a
wonderful and memorable event
for the members who made this trip.
Aural endoscopy being done byDr. Jeevanan with Dr. Harvinderlooking on and surrounded by
curious onlookers
Malaysian Society of
Otorhinolaryngologists
MSO-HNS Secretariat
19, Jalan Folly Barat,
50480, Kuala Lumpur.
Phone: 03-20930100
Fax: 03-20930900
E-mail:
We’re on the web! Visit
http://www.msohns.com!
Please direct all letters,
article submissions, picture
quizzes and suggestions to
The Editor,
Newsletter of the MSOHNS,
at the address above or to:
For the first time, a one day
symposium on thyroid disease
and surgery was organized by
the society for Otorhinolary-
ngologists and Surgeons at
the Hilton Kuala Lumpur on the
20th of November 2005. Invited
faculty included Professor Shahid
Hassan of USM, Dr. Zulkarnain
Hanaffi from Brunei Darussalam,
Dr Hisham Abdullah, Endocrine
Surgeon from Hospital Putrajaya,
Professor Abdullah Sani from
UKM and the organizing Chairman
Dr. Kuljit Singh of UMMC. The
domain of thyroid surgery has
always been in the hands of the
General Surgeon and the role of
the ENT surgeon thus far has
been the vocal cord assessment
pre-operatively and managing
the pa ra l yzed voca l co rds
following thyroid surgery. From
the response to the symposium
The MSO HNS annual Health
Camp was conducted this year
in Pulau Redang, Terengganu
under the able chairmanship of
Dr. Amran bin Mohamad together
w i th h is team f rom Hosp i ta l
Kuala Terengganu. A team of 20
ENT surgeons from all over the
country along with audiologists
and allied health personnel from
the Health Ministry of Terengganu
came together to participate in
this annual event.
The camp was held on the 1st of
April in the only primary school
on the island. Unfortunately the
men folk had gone to the sea so
we only managed to see a few
senior citizens, the ladies and
loads of kids with the usual
pediatric ENT problems. The kids
as usual were a curious lot and
were especially intrigued when
endoscopies were done. The
services of Dr. Hashim, (President’s
husband) an ophthalmologist
was truly appreciated as there
was a local outbreak of con-
junctivitis during our visit.
Hearing screening tests were
also performed and routine blood
pressure and b lood sugar
monitoring was done as well. Two
interesting tests were the body
fat density measurement and the
f i tness level measure were
favorites especially among the
well-endowed people who were
supposed to be conducting the
camp (I was one of them too).
After completing the camp, it was
time for the team to have its
recreational fun. This started with