Philippine Journal of Otolaryngology Head and Neck Surgery

An Alternative Surgical Approach to Cemento-Ossifying Fibroma of the Maxilla

2022-11-02T19:31:22-07:00

Objective: To report an alternative combined gingivobuccal and endoscopic endonasal approach to treating ossifying fibroma of the left maxilla.

Methods:
Design: Case Report
Setting: Tertiary Private University Hospital
Patient: A 19-year-old girl with a progressively enlarging left cheek mass for 3 years.
Results: Our patient underwent left medial maxillectomy via a combined gingivobuccal and endoscopic endonasal approach with complete resection and significant improvement of symptoms, with good functional outcome.
Conclusion: Large ossifying fibromas of the maxilla can be completely and successfully excised via a combined gingivobuccal and endoscopic endonasal approach.

Sudden Sensorineural Hearing Loss from a Jugular Bulb Diverticulum

2023-11-19T19:27:58-08:00

A 19-year-old woman presented with an 11-month history of sudden-onset left sided hearing loss accompanied by vertigo and headache. Audiometric testing revealed profound left- sided hearing loss. A contrast-enhanced MRI of the internal auditory canal performed 5 months after symptom onset was interpreted as showing a vascular loop, probably the anterior inferior cerebellar artery, abutting and indenting on the left vestibulocochlear nerve; and a prominent and high-riding left jugular bulb. In this study, the internal auditory canals were assessed to be of normal width, with walls that were smooth and sharply defined. A cerebral CT angiogram subsequently performed did not show any abnormal findings related to the previously identified vascular loop. On the basis of these radiologic findings, the patient was advised surgery by physicians at a tertiary- care institution, presumably to address the identified vascular loop. A second opinion was sought by the patient.

Review of the MRI initially focused on the axial high-resolution T2-weighted sequence (T2-DRIVE), as the fast spin-echo T2-weighted sequence has been recommended as a reliable and cost-effective MR screening protocol for the detection of masses in the IAC.¹ In contrast to the official radiology report, stenosis of the left internal auditory canal by a protrusion (Figure 1, white asterisk) originating from the posteromedial wall of the internal auditory canal was noted. This protrusion, which had no MR signal intensity, appeared to abut and compress the cranial nerves within the IAC. Reconstruction of the images in non-orthogonal planes aligned with the orientation and direction of the left 8^th cranial nerve showed the protrusion causing upward compression on and distortion of the nerve. (Figure 2, white arrows)

Attention was directed to the axial high-resolution T1-weighted sequence (T1W-3D FFE), which revealed that the protrusion contained an isointense soft tissue structure (Figure 3, white asterisk) located within the petrous bone medial to the posterior semicircular canal. This structure appeared to be an upward extension of the jugular bulb.

The axial high-resolution contrast-enhanced T1-weighted sequence (T1W-3D TFE Gd) showed smooth, vivid enhancement of the identified structure (Figure 4, black asterisk), which connected with the sigmoid sinus in lower cuts. This confirmed the presence of a high-riding jugular bulb that encroached on the internal auditory canal.

Any doubt as to its true nature was dispelled by a review of the temporal bone structures on high-resolution CT which was fortunately available in the cerebral CT angiogram. This revealed a protrusion of the high-riding jugular bulb with a waist-like margin (Figure 5A and B, black arrows), allowing further characterization of the lesion as a jugular bulb diverticulum.²

A high-riding jugular bulb that projects into the middle ear is not an uncommon anatomic variation. On the other hand, a jugular bulb diverticulum, which is an outpouching of the jugular bulb that can extend superiorly, medially, and posteriorly in the petrous bone, is a true venous anomaly that has been described rarely in the medical literature.^3,4 When symptomatic, patients with this anomaly can present with sensorineural hearing loss, tinnitus, vertigo and auricular pain.^3-5 Proper identification of a jugular bulb diverticulum in the evaluation of a patient with neurotologic symptoms is necessary to avoid inappropriate medical and surgical intervention.

As demonstrated in this patient, a jugular bulb diverticulum may not be identified by a screening MRI that utilizes only a T2-weighted sequence. T1-weighted MRI sequences with and without contrast are necessary to demonstrate its soft tissue imaging characteristics. Although not the initial imaging study of choice for sudden sensorineural hearing loss, high-resolution bone-window CT may be necessary to delineate the bony anatomy of the jugular foramen and confirm the presence of this anomaly.

Diagnosis and Management of Otosclerosis in a Filipino Population

2023-07-28T02:49:04-07:00

OBJECTIVE :

This case series aims to describe the diagnosis and management of otosclerosis in a series of Filipino patients encountered in a private, subspecialty otologic clinical practice. In particular, it elucidates the demographics, clinical presentation, diagnostic exam findings, clinical intervention and hearing outcomes.

METHODS :

Study Design : Retrospective review of medical records of a case series

Setting : Subspecialty otologic / neurotologic clinical practice

Participants : Medical records of all patients diagnosed to have otosclerosis based on radiologic evidence of fenestral or retrofenestral otosclerosis and/or confirmed during surgical exploration of the middle ear, during the period 2004-2017.

RESULTS :

Nine patients with otosclerosis were identified. Most patients presented with bilateral, primarily conductive hearing loss in middle age. However, an adolescent patient was also identified. Most patients were from the component cities of the National Capital Region. However, patients from the Cordillera region and south-central Mindanao were also identified. Radiologic evidence of fenestral or retrofenestral otosclerosis was identified in the majority of patients. However, readings of normal temporal bone CT findings were also seen. Obliterative otosclerosis was identified in one patient. Both objective and subjective evidence of hearing improvement was documented after stapedectomy in patients undergoing surgery.

CONCLUSIONS :

This study documents the presence of clinical otosclerosis in a Filipino population. As in other populations, it typically presents in middle age as a bilateral, primarily conductive hearing loss. However, a younger age does not preclude its diagnosis, as juvenile otosclerosis has been identified. The presence of patients in regions of the Philippines other than the National Capital Region implies that it has to be considered even in regional populations without a racial predilection for otosclerosis. The identification of radiologic evidence of fenestral and retrofenestral otosclerosis on CT imaging of the temporal bone makes this is an essential part of the work-up of Filipino patients with conductive hearing loss and normal otologic examinations. Surgical treatment via stapes surgery is an effective and viable option in the management of Filipino patients with otosclerosis. The identification of less common variants such as obliterative otosclerosis indicates the need for specialized surgical equipment and appropriate surgical training in order to successfully deal with these situations.

Radiographic Measurement of Nasopharyngeal Depth from the Anterior Nasal Spine (ND-ANS) Among Filipino Adults

2023-11-20T00:50:50-08:00

Objective: To determine a normative value for the nasopharyngeal depth from the anterior nasal spine (ND-ANS) among normal adult Filipinos using Computed Tomography scans.

Methods:
Design: Cross-sectional study
Setting: Tertiary National University Hospital
Participants: Of 516 adult patients that underwent facial, neck and temporal bone CT scans in our hospital between January 1 to June 30, 2019, 100 cases were randomized to be included in the study and 91 CT scans were analyzed.

Results: The mean nasopharyngeal depth from the anterior nasal spine among Filipino adults is 7.17 ± 0.42. There was a significant difference between sexes with a mean measurement of 7.23 cm ± 0.44 in males and 7.09 ± 0.37 cm in females. There was no statistically significant difference in mean nasopharyngeal depth across age groups.

Conclusion: A statistically significant difference was observed between sexes in our study sample. Our study provides initial normative values of nasopharyngeal depth among adult Filipinos, and additional studies may use this as a basis for further research.

Factors Predisposing to Post Thyroidectomy Vocal Cord Paralysis at Ospital ng Maynila Medical Center

2023-11-20T00:21:44-08:00

Objective: To determine the prevalence of vocal cord paralysis among post thyroidectomy patients based on severity and laterality, and explore possible associations with age, sex, diagnosis and type of thyroid lesion and surgical procedure.

Methods:
Design: Cross-sectional study
Setting: Tertiary Government Training Hospital
Participants: Records of patients who underwent thyroidectomy under the Department of Otorhinolaryngology – Head and Neck Surgery of the Ospital ng Maynila Medical Center from January 1, 2014 to June 30, 2021.

Results: There were strong associations between the type of lesion and the presence of recurrent laryngeal nerve injury (V=.211, p=.001) and the diagnosis and the presence of RLNI (V=.245, p=.006). There were no significant associations between patient’s sex, age, diagnosis, type of thyroid lesion, surgical procedure with laterality and severity of RLNI. It was notable that all cases of bilateral recurrent laryngeal nerve injury were due to carcinoma only. Patients with malignant tumors were 2.8x (95% CI: 1.48-5.29) as likely to develop post surgical RLNI than those with benign tumors (p=.0015).

Conclusion: The factors that had a strong association with the presence of vocal cord paralysis among post-thyroidectomy patients were the diagnosis and type of thyroid lesion. Malignant thyroid lesions (specifically thyroid carcinoma) had a higher incidence of recurrent laryngeal nerve injury compared to benign thyroid lesions. More data from different institutions and including other predisposing factors may confirm our findings.

Association of Clinicodemographic Factors and Tissue Biopsy Results Among Patients with Thyroid Nodules at the Southern Philippines Medical Center

2023-11-19T23:53:25-08:00

Objective: To compare selected clinicodemographic factors of patients with thyroid nodules who underwent thyroid surgeries with their tissue biopsy results and determine any association between clinicodemographic factors and tissue biopsy results.

Methods:
Design: Retrospective review of records
Setting: Tertiary Government Training Hospital
Participants: 251 patients with thyroid nodules

Results: Of 251 patients with thyroid nodules, the majority (218; 86.9%) were females while 33 (13.1%) were males. The average age in years was 41.5±13.3 The same population also had malignant outcomes at 79.3%. Most of the patients did not have family history of thyroid malignancy (54%) and had no palpable cervical lymph nodes at presentation (75.9%). Furthermore, there was no distant metastasis at presentation for both lungs (97.7%) and bones (98.9%). There were no significant differences in tissue biopsy results when correlated with age (df=249; t=-.144; p = .886), duration of goiter (df=249; t=-.829; p = .408), and distant metastasis at presentation for lungs (Z=-5.977; p = .052) and bones (Z=-.457; p = .648). Significant differences were only evident for clinicodemographic factors such as sex (Z=-2.570; p = .010), family history (Z=-2.239; p = .020), palpable cervical lymph nodes at presentation (Z=-5.977; p = .000), and the following comorbidities: pulmonary tuberculosis (Z=-2.388; p = .017) and bronchial asthma (Z=-2.148; p = .032) and smoking history (Z=-3.455; p=.001). Furthermore, having no palpable cervical lymph nodes at presentation were associated with malignant tissue biopsy results (B=3.616; p=.001). Patients without palpable cervical lymph nodes at presentation were 37.204 times [OR=37.204] more likely to have benign biopsy results [95% CI: 4.705 – 294.168].

Conclusion: There are greater odds of having benign biopsy results for patients without palpable cervical lymph nodes at presentation.

Relationship of Post-Thyroidectomy Hypocalcemia to Surgeon’s Experience in a Private Tertiary Hospital

2019-10-08T02:09:41-07:00

Objective:To determine the association of surgeon’s experience based on years of practice and incidence of post thyroidectomy hypocalcemia.

Methods:

Design: Retrospective cohort study
Setting: Tertiary Private Training Hospital
Participants: Records of patients who underwent total thyroidectomy in a private tertiary hospital from January 2003 to December 2018 were retrospectively reviewed. Medical information obtained were patient demographics, surgeon’s years of practice, thyroid specimen weight, technique of surgery, histopathologic findings and calcium assay values. Chi square test and Odds Ratio analysis were used to determine the relationship between the surgeon’s experience and post-thyroidectomy hypocalcemia.

Results:Three hundred fourteen (314) patients who underwent total thyroidectomy from 2003 to 2018 were included in the study. Overall rate of post-operative hypocalcemia was 41%. On multivariate analysis, no significant odds ratio was found between surgeons with 5 to 19 years of experience and those with more than 19 years of experience in relation to post-operative hypocalcemia [Odds Ratio 1.4 (95% Confidence Interval 0.7 to 2.6)]. Odds ratios for other variables may be interpreted, however, they could not be generalized over the population where data was gathered since the 95% Confidence Interval includes 1.

Conclusion: The results of this retrospective cohort study suggest that post-thyroidectomy hypocalcemia is not associated with surgeon’s experience based on years of practice. Further studies are recommended in a multicenter approach to better generalize to the whole population.

Surgical Management of Goiter with Intrathoracic Extension at the Philippine General Hospital Department of Otolaryngology Head and Neck Surgery

2022-10-09T20:19:20-07:00

Objective: To describe the demographic and clinical characteristics of patients diagnosed with intrathoracic thyroid masses managed surgically in our institution, determine associated factors affecting eventual operative approaches for these patients, and assess postoperative outcomes and complications associated with surgical intervention.

Methods:

Design: Retrospective descriptive case series

Setting:Tertiary National University Hospital

Participants: 24 patients

Results: The mean age of patients diagnosed with intrathoracic goiters was 55.71 years old, with a 1:1.4 male to female ratio; with most having an intrathoracic extent of Huins Grade 1 (67%) compared to others having Huins Grade 2-3. Majority of patients pre-operatively had a Fine Needle Aspiration (FNA) Bethesda Thyroid Nodule Classification of Category II (benign); 79% of total patients underwent excision of thyroid mass utilizing a transcervical approach alone. As Intrathoracic Extension (ITE) grade increased, additional transthoracic approaches were performed; duration of operation, average estimated blood loss, length of hospital stay was also noted to increase. Majority of post operative surgical histopathology results revealed malignant thyroid masses, in contrast to pre-operative FNA. Post-operative transient hypocalcemia was the most reported immediate complication.

Conclusions: Management of intrathoracic goiter is often multidisciplinary. Referral to the thoracic vascular service is warranted for access to the thoracic inlet. Classification by grade of intrathoracic goiters is helpful to determine the most appropriate operative approach and may
be predictive of intraoperative and postoperative outcomes. Postoperative histopathology across all ITE grades mostly yield malignant results; hence, preoperative FNA results should be used with caution.

Stratifying Indeterminate Cytology Thyroid Nodules by Combining Thyroid Imaging Reporting and Data Systems (TI-RADS) and The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC)

2021-10-02T08:12:54-07:00

Objective: To determine the risk of malignancy of Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) indeterminate Thyroid Nodules (Bethesda III, IV and V) by combining cytologic (TSBRTC) and Thyroid Imaging Reporting and Data Systems (TI-RADS) ultrasonographic features based on final histopathology.

Methods:
Design: Retrospective review of records
Setting: Tertiary Private Training Hospital
Participants: 551 records
Results: Among 81 eligible participants, 59 out of 84 nodules (70.24%) wer malignant on histopathology. The malignancy risk of Bethesda classification was 60.87% (28 out of 46) for Bethesda III, 57.14% (8 out of 14) for Bethesda IV and 95.83% for Bethesda V. The malignancy risk for TI-RADS categories was 0 % (0/1) for TI-RADS 2, 50% (10 out of 20) for TI-RADS 3, 71.05 % for TI-RADS 4 and 91.67 % for TI-RADS 5. The highest risk of malignancy (100%) was associated with [Bethesda IV/TI-RADS 1, 2, and 3], [Bethesda V/TI-RADS 1, 2 and 3 [Bethesda IV and V/TI-RADS 1, 2 and 3] and [Bethesda IV/TI-RADS 5]. The lowest risk of malignancy (33.33%) was associated with [Bethesda III/TI-RADS1, 2 and 3]. A high Bethesda classification (Bethesda V) was almost 5x more likely to have a malignant anatomorphology compared with Bethesda III (p = .05) while a TI-RADS 4 or 5 category was almost 5x more likely to have a malignant anatomorphology compared to TI-RADS 1, 2 or 3 (p = .026).

Conclusion: This study showed that TI-RADS scoring is a sensitive diagnostic classification in recognizing patients with thyroid cancer and combining Bethesda classification and TI-RADS scoring increases the sensitivity in the diagnosis of malignant thyroid nodules. A higher likelihood of malignancy is associated with higher Bethesda classification and TI-RADS scoring.

Contents Vol. 38 No. 2 July-December 2023

2023-11-20T03:43:18-08:00

EDITORIAL
4
On the Brink: The Climate and Nature Crisis and Risks of Nuclear War

Lapeña JFF

GUEST EDITORIALS
6
Time to Treat the Climate and Nature Crisis as One Indivisible Global Health Emergency

Abbasi K, Ali P, Barbour V, Benfield T, Bibbins-Domingo K, Hancocks S, Horton R, Laybourn-Langton L, Mash R, Sahni P, Mohammad Sharief W, Shehab A, Yonga P, Zielinski C

9
Reducing the Risks of Nuclear War – The Role of Health Professionals
Abbasi K, Ali P, Barbour V, Bibbins-Domingo K, Olde Rikkert MGM, Haines A, Helfand I, Horton R, Mash R, Mitra A, Monteiro C, Naumova EN, Rubin EJ, Ruff T, Sahni P, Tumwine J, Yonga P, Zielinski C

ORIGINAL ARTICLES

11
Diagnosis and Management of Otosclerosis in a Filipino Population: A Case Series
Yang NW

17
Radiographic Measurement of Nasopharyngeal Depth from the Anterior Nasal Spine (ND-ANS) Among Filipino Adults
Lopa RAB, Ilustre GMS, Hernandez JG

22
Factors Predisposing to Post Thyroidectomy Vocal Cord Paralysis at Ospital ng Maynila Medical Cente
Carlos EJC, Agullo EJA

26
Association of Clinicodemographic Factors and Tissue Biopsy Results Among Patients with Thyroid Nodules at the Southern Philippines Medical Center
Aujero ML, Tagsa JMP, Llamera GLQ

31
Relationship of Post-Thyroidectomy Hypocalcemia to Surgeon’s Experience in a Private Tertiary Hospital
Ramos NP

35
Surgical Management of Goiter with Intrathoracic Extension at the Philippine General Hospital Department of Otolaryngology – Head and Neck Surgery
Mendoza KML, Madrid DAD

42
Stratifying Indeterminate Cytology Thyroid Nodules by Combining Thyroid Imaging Reporting and Data Systems (TI-RADS) and The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC)
Cambe SMM, Arañas JAM, Manzana JLP, Manlapaz KTG

SURGICAL INNOVATIONS AND INSTRUMENTATION

48
An Alternative Surgical Approach to Cemento Ossifying Fibroma of the Maxilla
Santos JE, Gelera JE

PRACTICE PEARLS

52
Use of Sail Excision in Alar Morphology Modification of Asian Noses
Regalado-Go JAF, Yap EC

FEATURED GRAND ROUNDS

59
Hemangioma of the Mandible in a 12-Year-Old Boy
Marasigan DAR, Carabeo PJF, Castañeda SS

FROM THE VIEWBOX

64
Sudden Sensorineural Hearing Loss from a Jugular Bulb Diverticulum
Yang NW

UNDER THE MICROSCOPE

67
Nasal Gouty Tophus
Delmendo MPEM, Chang AMV

PASSAGES

69
Nixon S. See, MD
Alcira RCV

CAPTOONS

70
DokNet’s World
Billones WU

Nasal Gouty Tophus

2023-02-11T03:44:14-08:00

A 48-year-old, non-hypertensive, non diabetic man with uncontrolled gouty arthritis presented with a four-day swollen nasal mass. He was assessed to have a nasal abscess at the emergency room and was admitted for urgent management. Paranasal computed tomography (CT) scans showed a heterogeneously enhancing focus with areas of hypodensities in the nasal apex and dorsum extending into the right ala measuring 1.5 x 2.8 x 3.4 cm. with associated erosion of the cartilaginous part of the anterior nasal septum, soft tissue swelling and skin thickening in the nasal dorsum, nasal tip and right zygomatic region that was suspected to relate to an aggressive etiology. Tissue correlation was therefore recommended, and he underwent endoscopic-guided incision and drainage with biopsy and debridement of the nasal mass.

The specimen submitted consisted of red to white, irregular, soft tissue fragments with an aggregate measurement of 1.5 x 1.5 x 0.5 cm. Microsections showed deposits of amorphous white to pink material with surrounding fibrosis and acute and chronic inflammatory cell infiltrates and foreign body giant cells. (Figures 1 and 2) Also seen in the background were fragments of sclerotic bone and bacterial colonies. These findings were consistent with gouty tophus with acute and chronic inflammation and bacterial colonization. The culture and sensitivity test of the nasal discharge showed growth of Enterobacter aerogenes (currently named Klebsiella aerogenes) which was identified by an automated mass spectrometry microbial identification system (VITEK® MS). Work-up also included uric acid levels which were within the reference interval at that time (6.57 mg/dL).

Nixon S. See, MD (1962-2023)

2023-11-20T01:50:22-08:00

While I am honored to be chosen among his many friends to pay tribute to him, I am struck by ambivalence, as I mourn just as deeply for Nixon’s passing. Nevertheless, as this is likely my last opportunity to praise this great man, I aim to give a good accounting of his life and times.

Nix and I first met as applicants of the residency program in ORL-HNS at the Ospital ng Maynila Medical Center (OMMC) in September 1989. Subsequently, he established his practice in his hometown of Calapan, Oriental Mindoro. He was briefly affiliated with the PSO-HNS Southern Tagalog Chapter as a charter member but was forced to relinquish this and a flourishing practice and return to Manila to care for his wife. He joined the Fatima University Medical Center and College of Medicine, eventually becoming chairman of the Department of ORL-HNS. He rejoined OMMC as consultant in 2010.

Having been his close friend for more than three decades, I have known him to be a peaceful man. Indeed, he abhorred life’s unnecessary complexities, wanting only a simple, quiet life, content in the knowledge that he has filled the cups of those whose lives he had touched.

I use PEACEFUL, not only in a literal sense, but also as an acronym that represents his qualities I have learned to love, as well as hate. Nix was a Principled man, to the point of being stubborn. His moral compass was always straight and true, unwavering, and without any gray areas. He was also a Practical man, choosing to be frugal for himself, yet generous to his family. He was Exacting, meticulously insisting on accomplishing tasks in a specific, almost textbook-like manner. “So-so” was not in his vocabulary. An Amiable individual, he was never aloof and was ready to greet anyone with a genuine smile. He chose to live Cleanly, leading a life not only free of vices, but one pursued with healthy physical activity. Being meticulously principled was not without its drawbacks. He was Cranky. During a typical cantankerous mood, he would wipe his face with his palm, as if to “erase” it. This was followed by a long, deep snort. Woe to the junior resident who would earn his ire! I would remember him say: “though I’m a specialist, I don’t think I will ever become filthy rich.” He was a man of charity, an Expert physician: competent, conscientious, caring, and humane. He was a devout Family man, one whose decisions, without exception, revolved around the welfare of his loved ones. While he reached impressive heights professionally, he remained grounded and Unassuming, a true epitome of humility. Lastly, he was a Loyal friend to the end.

I have lost a brother. Yet, during his final days, having witnessed how his illness ravaged his physical form relentlessly, mercilessly, I take solace in the knowledge that he is now in a place of eternal serenity, free of doubt, fear, and despair. I once read: God is indeed wise because He placed death at the end of life and not at its beginning. Truer words have never been said, for it allowed me to experience the richness of life with Nix. To my friend, I say: “Till we meet again.”

DokNet’s World

2023-11-19T17:28:44-08:00

On the Brink: The Climate and Nature Crisis and Risks of Nuclear War

2023-11-20T04:04:18-08:00

The Russian military invasion of Ukraine on February 24, 2022, and Hamas’ terror attack on Israel on October 7, 2023, signaled the beginning of two of the most recent wars to make international headlines. To date, over 110 armed conflicts are taking place: over 45 in the Middle East and North Africa (Cyprus, Egypt, Iraq, Israel, Libya, Morocco, Palestine, Syria, Turkey, Yemen, Western Sahara); over 35 in Africa (Burkina Faso, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Ethiopia, Mali, Mozambique, Nigeria, Senegal, Somalia, South Sudan, Sudan); 21 in Asia (Afghanistan, India, Myanmar, Pakistan, the Philippines); seven in Europe (Russia, Ukraine, Moldova, Georgia, Armenia, Azerbaijan); and six in Latin America (three each in Mexico and Colombia); with two more international armed conflicts (between India and Pakistan, and between India and China) in Asia.¹ This list does not even include such problematic situations as those involving China and the South East Asia region.

As though these situations of armed violence were not enough, mankind has already passed or is on the verge of passing several climate tipping points – a recent review lists nine Global core tipping elements (and their tipping points) - the Greenland Ice Sheet (collapse); West Antarctic Ice Sheet (collapse); Labrador-Irminger Seas / SPG Convection (collapse); East Antarctic Subglacial Basins (collapse); Amazon Rainforest (dieback); Boreal Permafrost (collapse); Atlantic M.O. Circulation (collapse); Arctic Winter Sea Ice (collapse); and East Antarctic Ice Sheet (collapse); and seven Regional impact tipping elements (and their tipping points) – Low-latitude Coral Reefs (die-off); Boreal Permafrost (abrupt thaw); Barents Sea Ice (abrupt loss); Mountain Glaciers (loss); Sahel and W. African Monsoon (greening); Boreal Forest (southern dieback); and Boreal Forest (northern expansion).² Closer to home, how can we forget the disaster and devastation wrought by Super Typhoon Haiyan (Yolanda) 10 years ago to date?

Whether international or non-international, armed conflicts raise the risk of nuclear war. Russia has already “rehearsed its ability to deliver a ‘massive’ nuclear strike,” conducting “practical launches of ballistic and cruise missiles,” and stationed a first batch of tactical nuclear weapons in Belarus,³ and the possibility of nuclear escalation in Ukraine cannot be overestimated.⁴ Meanwhile, in a rare public announcement, the U.S. Central Command revealed that an Ohio- class submarine (560 feet long, 18,750 tons submerged and carrying as many as 154 Tomahawk cruise missiles) had arrived in the Middle East on November 5, 2023.5 Indeed, “the danger is great and growing,” as “any use of nuclear weapons would be catastrophic for humanity.”⁶

Hemangioma of the Mandible in a 12-Year-Old Boy

2021-03-30T21:47:51-07:00

Intraosseous hemangioma is a benign, rare neoplasm that accounts to 0.5 - 1% of all benign tumors of bones.^{1, 2} While most hemangiomas arise from soft tissues, it is uncommon for it to arise from bones.² The most common sites of growth are in the vertebral body and the calvarium with frontal bone making up approximately 45% of calvarial cases.^2,3 However, they are also encountered in the head and neck with sites such as the skull (53%), mandible (10.7%), nasal bones (9%), and cervical spine (6%).⁴ In the mandible, the body is mostly affected and 65% are found in the molar and premolar region.1 They are more common in adult females with peaks at the second and fifth decades of life.^1-3

Hemangioma of the mandible is difficult to diagnose due to its nonspecific clinical presentation and radiographic features. It mimics various mass lesions in the mandible such as giant cell granuloma, fibrous dysplasia, multiple myeloma, osteosarcoma, ameloblastoma and keratocysts. Therefore, a comprehensive history taking and physical examination plus examination of the imaging studies available and tissue biopsy all play important roles in arriving at the final diagnosis.⁵

We present the case of an aggressive mandibular hemangioma in a young boy and our management involving a failed fibular free flap reconstruction.

Use of Sail Excision in Alar Morphology Modification of Asian Noses

2023-03-15T15:53:51-07:00

Globular hanging nasal alae, described as convex round shaped alar lobule which may be an aesthetic nuisance in the final result of rhinoplasty, are commonly seen among Southeast Asian noses. Such alar lobule morphology is an important part of nasal aesthetics and should not be disregarded. Surgical techniques used to address a hanging ala include direct external approaches. External rim excision was proposed to address hidden columella, sigmoid alae, small nostrils, dropped rim and foreshortened nose.^1,2 Rim tissue was excised in full thickness fashion and sutured in one layer. Others proposed alar groove excision followed by alar repositioning and full-thickness skin grafting to reposition the alar base and correct hanging alae.³ Although these approaches have been proven to correct hanging alae, they leave a visible scar and/or permanent alar rim deformity if not done cautiously, especially on thick skinned patients.^1-3 The alar rim may not be natural looking since it is lined by a scar, thus losing the lobular texture of the rim. A vestibular incision has been proposed to correct a hanging ala with unsightly scar.⁴ A maximum of 3mm elliptical vestibular skin was recommended to be removed to lift the alar rim with significant results. However, this recommendation was based on estimates and surgeon’s experience in western noses and may be insufficient for Asian noses. In addition, performing this technique without specific landmarks is difficult in achieving accurate results, especially when performed by a novice surgeon. Hence, further modification is important to address these concerns.

Attempting to address the hanging alae in Asian noses, the senior author (ECY) modified the vestibular incision and came up with the sail excision technique based on the patient’s nasal anatomy.⁵ By presenting definite landmarks, the technique resulted in an alar lift procedure with reproducible outcomes. Furthermore, after performing sail excision in several patients, the authors noted the effect of this technique on alar morphology. This procedure is done by excising a precisely marked piece of inner nasal vestibular skin that is shaped like the sail of a boat to achieve a symmetrical and redictable result. This creates a lifting effect and improves the alar columellar disproportion specially when combined with septal advancement techniques.^6,7

Furthermore, limiting the excision along the inner vestibular area and rolling the alar rim skin inwards results in correction of hanging ala (with a hidden scar) without an obvious, external scar. After performing the technique on several patients, we observed that in addition to its effect on lifting a hanging ala, the sail excision technique also changes the alar morphology from a globular-shaped lobule to a more aesthetically pleasing ridge-shaped lobule. To the best of our knowledge, such an effect of sail excision on alar morphology has not been described in the literature.

This article aims to demonstrate the effect of the sail excision technique on alar rim morphology of Asian noses by describing the step-by-step procedure, surgical landmarks, and pearls in performing this technique.

Time to Treat the Climate and Nature Crisis as One Indivisible Global Health Emergency

2023-11-19T21:18:02-08:00

Over 200 health journals call on the United Nations, political leaders, and health professionals to recognise that climate change and biodiversity loss are one indivisible crisis and must be tackled together to preserve health and avoid catastrophe. This overall environmental crisis is now so severe as to be a global health emergency.

The world is currently responding to the climate crisis and the nature crisis as if they were separate challenges. This is a dangerous mistake. The 28^th Conference of the Parties (COP) on climate change is about to be held in Dubai while the 16^th COP on biodiversity is due to be held in Turkey in 2024. The research communities that provide the evidence for the two COPs are unfortunately largely separate, but they were brought together for a workshop in 2020 when they concluded that: “Only by considering climate and biodiversity as parts of the same complex problem...can solutions be developed that avoid maladaptation and maximize the beneficial outcomes.”¹

As the health world has recognised with the development of the concept of planetary health, the natural world is made up of one overall interdependent system. Damage to one subsystem can create feedback that damages another—for example, drought, wildfires, floods and the other effects of rising global temperatures destroy plant life, and lead to soil erosion and so inhibit carbon storage, which means more global warming.² Climate change is set to overtake deforestation and other land-use change as the primary driver of nature loss.³

Nature has a remarkable power to restore. For example, deforested land can revert to forest through natural regeneration, and marine phytoplankton, which act as natural carbon stores, turn over one billion tonnes of photosynthesising biomass every eight days.⁴ Indigenous land and sea management has a particularly important role to play in regeneration and continuing care.⁵

Restoring one subsystem can help another—for example, replenishing soil could help remove greenhouse gases from the atmosphere on a vast scale.⁶ But actions that may benefit one subsystem can harm another—for example, planting forests with one type of tree can remove carbon dioxide from the air but can damage the biodiversity that is fundamental to healthy ecosystems.⁷

Reducing the Risks of Nuclear War— the Role of Health Professionals

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In January, 2023, the Science and Security Board of the Bulletin of the Atomic Scientists moved the hands of the Doomsday Clock forward to 90’s before midnight, reflecting the growing risk of nuclear war.¹In August, 2022, the UN Secretary-General António Guterres warned that the world is now in “a time of nuclear danger not seen since the height of the Cold War.² The danger has been underlined by growing tensions between many nuclear armed states.^1,3 As editors of health and medical journals worldwide, we call on health professionals to alert the public and our leaders to this major danger to public health and the essential life support systems of the planet—and urge action to prevent it.

Current nuclear arms control and non-proliferation efforts are inadequate to protect the world’s population against the threat of nuclear war by design, error or miscalculation. The Treaty on the Non-Proliferation of Nuclear Weapons (NPT) commits each of the 190 participating nations ”to pursue negotiations in good faith on effective measures relating to cessation of the nuclear arms race at an early date and to nuclear disarmament, and on a treaty on general and complete disarmament under strict and effective international control”.⁴ Progress has been disappointingly slow and the most recent NPT review conference in 2022 ended without an agreed statement.⁵ There are many examples of near disasters that have exposed the risks of depending on nuclear deterrence for the indefinite future.⁶ Modernisation of nuclear arsenals could increase risks: for example, hypersonic missiles decrease the time available to distinguish between an attack and a false alarm, increasing the likelihood of rapid escalation.

Any use of nuclear weapons would be catastrophic for humanity. Even a “limited” nuclear war involving only 250 of the 13,000 nuclear weapons in the world could kill 120 million people outright and cause global climate disruption leading to a nuclear famine, putting 2 billion people at risk.^7,8 A large-scale nuclear war between the USA and Russia could kill 200 million people or more in the near term, and potentially cause a global “nuclear winter” that could kill 5–6 billion people, threatening the survival of humanity.^7,8 Once a nuclear weapon is detonated, escalation to all-out nuclear war could occur rapidly. The prevention of any use of nuclear weapons is therefore an urgent public health priority and fundamental steps must also be taken to address the root cause of the problem—by abolishing nuclear weapons.

The health community has had a crucial role in efforts to reduce the risk of nuclear war and must continue to do so in the future.⁹In the 1980s the efforts of health professionals, led by the International Physicians for the Prevention of Nuclear War (IPPNW), helped to end the Cold War arms race by educating policy makers and the public on both sides of the Iron Curtain about the medical consequences of nuclear war. This was recognised when the 1985 Nobel Peace Prize was awarded to the IPPNW.¹⁰(http://www.ippnw.org).

In 2007, the IPPNW launched the International Campaign to Abolish Nuclear Weapons, which grew into a global civil society campaign with hundreds of partner organisations. A pathway to nuclear abolition was created with the adoption of the Treaty on the Prohibition of Nuclear Weapons in 2017, for which the International Campaign to Abolish Nuclear Weapons was awarded the 2017 Nobel Peace Prize. International medical organisations, including the International Committee of the Red Cross, the IPPNW, the World Medical Association, the World Federation of Public Health Associations, and the International Council of Nurses, had key roles in the process leading up to the negotiations, and in the negotiations themselves, presenting the scientific evidence about the catastrophic health and environmental consequences of nuclear weapons and nuclear war. They continued this important collaboration during the First Meeting of the States Parties to the Treaty on the Prohibition of Nuclear Weapons, which currently has 92 signatories, including 68 member states.¹¹

We now call on health professional associations to inform their members worldwide about the threat to human survival and to join with the IPPNW to support efforts to reduce the near-term risks of nuclear war, including three immediate steps on the part of nuclear- armed states and their allies: first, adopt a no first use policy;¹² second, take their nuclear weapons off hair-trigger alert; and, third, urge all states involved in current conflicts to pledge publicly and unequivocally that they will not use nuclear weapons in these conflicts. We further ask them to work for a definitive end to the nuclear threat by supporting the urgent commencement of negotiations among the nuclear-armed states for a verifiable, timebound agreement to eliminate their nuclear weapons in accordance with commitments in the NPT, opening the way for all nations to join the Treaty on the Prohibition of Nuclear Weapons.

The danger is great and growing. The nuclear armed states must eliminate their nuclear arsenals before they eliminate us. The health community played a decisive part during the Cold War and more recently in the development of the Treaty on the Prohibition of Nuclear Weapons. We must take up this challenge again as an urgent priority, working with renewed energy to reduce the risks of nuclear war and to eliminate nuclear weapons.

Message

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This year, we celebrate the 67th year of the Philippine Society of Otolaryngology-Head and Neck Surgery. It is a memorable year not only for us ENT practitioners but for the entire world as well, because after 3 years of restrictions, our lives and activities are finally back to normal. The vaccines and medicines against COVID-19 that were developed through meticulous research have afforded us protection against the virus and the confidence to return to our daily lives. Now, more than ever, we see the vital role of research in our lives.

Research. It is a word that we are all familiar with and have encountered countless times throughout our lives. It is a search for new knowledge to expand our expertise and answer the questions we have. Every carefully chosen article and piece of research published in this issue seeks to promote and enhance the practice of Otolaryngology. As you read through them, I hope that they expand your understanding of our specialty and gain new knowledge that you can use to improve your practice.

I would like to thank our contributors and the members of the editorial staff of the Philippine Journal of Otolaryngology – Head and Neck Surgery, headed by Dr. José Florencio Lapeña, for their unwavering commitment to regularly provide us new articles and studies to ignite our thirst for knowledge and research. Congratulations for another successful publication and we eagerly anticipate the next one.

Enjoy reading!