Philippine Journal of Otolaryngology Head and Neck Surgery

Synchronous Primary Head and Neck Tumors: Follicular Thyroid Carcinoma and Squamous Cell Carcinoma of The Tonsil

Princess B. Maristela, MD, Emmanuel Tadeus S. Cruz, MD — Tue, 28 May 2024 00:00:00 -0700

Simultaneously occurring malignancies may be detected in different organs or tissues at any given time. Patients diagnosed with a tumor may be found to have another tumor or second primary cancer. Second primary cancers (SPCs) may be further classified as synchronous or metachronous. Synchronous SPCs are lesions detected simultaneously or within 6 months after the diagnosis of the primary tumor while metachronous SPCs are tumors diagnosed 6 months after primary tumor diagnosis.¹

There is an increased risk of having second primary cancer in Head and Neck Squamous Cell Carcinoma (HNSCC) patients.¹ In a study by Strojan et al. in 2013, among 2,106 head and neck cancer patients, 2.4% developed synchronous second primary cancers.² A systematic review by Coco-Pelaz et al. in 2020, showed that second primary tumors most frequently occur in the head and neck area followed by the lungs and esophagus.³

We present a case of follicular thyroid carcinoma with an incidental finding of cervical lymph node metastatic squamous cell carcinoma from the tonsil and discuss the clinical presentation, ancillary procedures and management.

A Prototype 3D Printed Suction Port Adapter for a Wireless Otoendoscope

Ma. Cristina Z. Garcia, MD, Jay Pee M. Amable, MD — Tue, 28 May 2024 00:00:00 -0700

ABSTRACT
Objective: To design and fabricate a suction port adapter to use various sizes of suction cannulas
with a wireless otoendoscope enabling ear cleaning under endoscopic guidance demonstrated using an ear examination simulator.

Methods:
Design: Instrument Innovation
Setting: Tertiary Private Training Hospital
Patient: Ear Examination Simulator

Results: The fabricated suction port adapters were able to hold the wireless otoendoscope and suction cannulas together, allowing simultaneous inspection of the ear canal and suctioning of ear canal debris using the Ear Examination Simulator

Conclusion: Our prototype 3D-printed suction port adapters for a wireless otoendoscope may
improve ear cleaning by enhancing the accuracy of suctioning debris and decreasing duration
since they hold the suction cannulas in place under endoscopic guidance. They may aid ENT
physicians in easier visualization and simultaneous ear cleaning of patients and improve ear
cleaning techniques and times, especially among less experienced physicians, but actual clinical
trials are needed to confirm this.

Message

Christine Joy S. Arquiza, MD — Tue, 28 May 2024 00:00:00 -0700

Greetings!
Warm congratulations to the Editorial Board of the Philippine Journal of Otolaryngology – Head and Neck Surgery (PJO-HNS), headed by Dr. Jose Florencio Lapeña, on the publication of this issue. The Philippine Society of Otolaryngology-Head and Neck Surgery (PSO-HNS) is proud to have such an eminent team curating and reviewing research articles from specialists from all over the world in order to provide the PSO-HNS Fellows and the wider medical community with information essential to the practice of ORL-HNS.

The primary purpose of the PSO-HNS is to engage in the promotion of the welfare, training, and scientific advancement of ORL-HNS in the Philippines; in particular (among many other objectives): to develop programs to promote the exchange of scientific information among members, and to encourage, support and institute publication of scientific ORL-HNS literature for national and international consumption. Considering the journal that you are currently reading, I declare success in achieving these objectives.

Our Society has been growing and evolving through the years, and the PJO-HNS is proof that PSO-HNS is now more than just a social organization. We are a force for good of ORL-HNS practice and optimum patient welfare. If we are to continue taking the best care of our patients, we must practice evidence-based medicine, and research will be the bedrock on which we build.

I leave you with my life verse for this year. From Galatians 6:9 (NIV): “Let us not become weary in doing good, for at the proper time we will reap a harvest if we do not give up.”

Let us continue doing good for each Fellow, for the PSO-HNS as a whole, and for the Filipino people who need our care. May you be inspired to do good, to do research, and to do good research as you read this issue.

His Blessings!

Computed Tomography Analysis of the Anterior Epitympanic Recess and Sinus Tympani Depths Among Filipino Adults at the De La Salle University Medical Center

Giancarla Therese l. Gutierrez, MD — Tue, 28 May 2024 00:00:00 -0700

Objective: To assess the depths of the anterior epitympanic recess (AER) and the sinus tympani (ST) among Filipino adults and to classify the AER and ST according to grade and type, respectively.

Methods:

Design:Retrospective Review of CT Scans

Setting: Tertiary Private Teaching Hospital

Participants:Scans of 182 non-pathologic ears from patients aged 18 and above with non-pathologic temporal bones (paranasal sinus, screening sinus, temporal bone, facial and cranial) with 0.62mm cuts seen from CT scans from January 01, 2010 to September 31, 2022 were analyzed. The depths of the AER and ST were measured separately and classified according to AER grade and ST type.

Results: The mean depth of the AER (AER-D) was 3.64 mm (SD 1.17). No significant difference was seen between right and left ears. The AER grading of the anterior-posterior depth was found to be Grade 1 (<3mm) in 54 ears (29.7%), Grade 2 (3-5mm) in 106 ears (58.2%), and Grade 3 (>5mm) in 22 ears (12.1%). The mean depth of the sinus tympani (ST-D) was 3.30 mm (SD 0.80). Out of the 182 ears, 121 (66.5%) had Type A, 50 (27.5%) had Type B while 11 (6%) had Type C.

Conclusion: Majority of the AER depths measured 3-5mm while most of the sinus tympani were Type A. These hidden recesses should be separately analyzed in preoperative planning for cholesteatoma surgery in order to prepare the adequate equipment to be used and approach towards these areas thereby reducing the risk for residual cholesteatomas and recurrence.

Prevalence of and Risk Factors Associated with Methicillin-Resistant Staphylococcus aureus (MRSA) Carriage Among Cutting Specialties at the Ospital ng Maynila Medical Center

Michael Robert Q. Monteverde, MD, Ramon Carmelo V. Alcira, MD — Tue, 28 May 2024 00:00:00 -0700

Objective: To determine the point prevalence of, and risk factors associated with MRSA carriage among resident physicians of surgical departments at the Ospital ng Maynila Medical Center.

Methods:

Design: Cross-sectional Study

Setting: Tertiary Government Training Hospital

Participants:51 resident physicians from different surgical departments (general surgery, obstetrics and gynecology, ophthalmology, otorhinolaryngology – head and neck surgery and dermatology) underwent nasal and pharyngeal swabs with microbial culture and sensitivity testing to identify MRSA carriers. Fisher Exact Test and logistic regression were utilized to determine associations between MRSA carriage and various risk factors including frequency of hand washing and departmental affiliation.

Results: Overall prevalence rate of MRSA carriage was 9.8%. Otorhinolaryngology residents had the highest combined prevalence of MRSA of 42.9%, significantly higher compared to other departments and were used as a reference in logistic regression analyses. Notably, handwashing only once daily was associated with a 20-fold increase in the risk of MRSA carriage (OR 20.5, 95% CI: 1.82 to 230, p = .014). Other departments did not demonstrate statistically significant differences in MRSA carriage rates.

Conclusions: Otorhinolaryngology resident physicians had the highest combined prevalence of MRSA and nasal MRSA was found only in otorhinolaryngology residents. The surgical subspecialty and frequency of handwashing of the healthcare worker were identified as important risk factors to develop MRSA carriage. Targeted interventions (including enhanced infection control protocols and regular screening) are needed especially in high-risk departments.

Determination of the Relationship Between Olfactory Function Threshold and Quality of Life Among Adult Filipinos with Perceived Olfactory Dysfunction

Tue, 28 May 2024 00:00:00 -0700

Objective: To determine the relationship between olfactory function threshold and quality of life (QOL) among adult Filipinos with perceived olfactory dysfunction (OD).

Methods:

Design: Cross - Sectional Study

Setting: Tertiary Government Training Hospital

Participants: 98 adults who had self-perceived olfactory dysfunction described as “poor” or “no sense” of smell

Results: We analyzed data from 98 participants, with a mean age of 35.91 + 12.58 years old, composed of 46 men (47%) and 52 women (53%), with 82 normosmic, six hyposmic and ten anosmic as categorized by their BTT scores. Twenty-seven percent (27%) identified themselves as having poor QOL based on Fil 17 QODNS. Differences were exhibited between sexes’ BTT scores - [t(96) = -2.32; p = .022; females, M: 9.25; SD: 2.33 vs. males, M: 7.76; SD : 3.91], civil status Fil17QODNS scores [t(96)= 3.05, p < .003; married M: 11.72, SD: 13.74 vs. single, M: 4.71; SD: 8.66), and the presence of ENT symptoms BTT [t(96) = -7.15; p < .0001; symptomatic, M: 5.62; SD: 4.54, vs. asymptomatic, M: 9.78; SD: 1.14] and Fil 17 QODNS scores [t(96)= 3.94; P < .00001; symptomatic, M: 14.86; SD: 13.97] vs. asymptomatic, M: 5.217; SD: 9.60]. Significant risk factors were the presence of ENT symptoms [OR= 0.15; 95% CI: 0.02-0.97; P = .046] for poor smell threshold, and comorbidities [OR= 3.36; 95% CI: 1.04-10.85; P = .043] for poor QOL. A negative correlation was observed between Fil-QOD-NS scores and BTT scores [r = -0.477, p < .001; rs = -0.292, p = .004], signifying that the presence of olfactory dysfunction has an inverse relationship
with the quality of life.

Conclusion: Individuals with olfactory dysfunction in this study population had poor quality of life as determined by the translated Filipino 17-item QOD-NS which has an inverse relationship with their smell threshold as represented by the BTT results. Among the factors studied, significant differences were found between sexes, civil status and presence of ENT symptoms in the BTT and Fil 17 QODNS scores. However, only presence of comorbidities and ENT symptoms are significant risk factors for quality of life and smell threshold, respectively, in this population.

Clinicodemographic Profile and Treatment Outcomes of Patients with Upper Aerodigestive Tract Foreign Bodies in the Southern Philippines Medical Center: A Five-Year Retrospective Review

John Michael P. Tagsa, MD, Donnie Jan D. Segocio, MD — Tue, 28 May 2024 00:00:00 -0700

Objective: This study aims to describe the clinicodemographic profile of patients with foreign
bodies in the upper aerodigestive tract and their treatment outcomes.

Methods:

Design: Retrospective review of records

Setting: Tertiary Government Training Hospital

Participants: Records of 304 patients diagnosed with aerodigestive foreign bodies

Results: Three hundred-four (304) patients were included. The median age was 5.26 years in the pediatric age group and 42.53 years in the adult age group, with a male-to female ratio = 1.97:1. Foreign bodies were ingested in 291 (96%) patients while aspiration occurred in 13 (4%). Overall, 211 (69%) of cases involved the pediatric population (<19 years) and 93 (31%) the adult population. The most common foreign bodies reported were coins (63.5%), food (18.1%), and dentures (11.5%). Most esophageal foreign bodies (244/291; 83%) were seen at the cricopharyngeal level in all age groups. The foreign body was removed successfully in 288/291 (98%) of ingestion cases. All 13 cases of foreign body aspiration were successfully removed by bronchoscopy. All patients were discharged improved.

Conclusion: Most upper aerodigestive tract foreign bodies involved the pediatric age group.
Predisposing conditions were mainly due to accidental ingestion and aspiration while playing in the pediatric population and negligence in eating among adults. Almost all ingestion cases were successfully treated with esophagoscopy, while all aspirations were treated successfully with bronchoscopy. Most intraoperative and postoperative complications who were managed conservatively by observation, although some cases required referral to other surgical departments and were treated surgically. All patients were discharged improved

Clinical Care Pathway Time Intervals and Tumor Progression Among Head and Neck Cancer Patients at East Avenue Medical Center Before and During the COVID-19 Pandemic

Tue, 28 May 2024 00:00:00 -0700

Objective: To investigate the association between the time intervals of key clinical time points and tumor progression (increase in clinical staging) in head and neck cancer patients before and during the pandemic.

Methods:

Design: Retrospective Cohort Study

Setting: Tertiary Government Training Hospital

Participants: A total of 81 head and neck cancer patients who consulted at the OPD and underwent elective surgery between January 1, 2018, and December 31, 2022, under the Department of Otorhinolaryngology – Head and Neck Surgery of East Avenue Medical Center were included in the study; 40 patients comprised the pre-pandemic group and 41 patients-the pandemic group.

Results:Majority of patients were men (61.73%), and the mean age was 54 years. The most prevalent tumor site was the oral cavity (37.04%). Most patients were Clinical Stage IV at the time of diagnosis (32.10%) and at the time of surgery (58.02%). In the pre-pandemic period, median time-to-consult was 180 days, time-to-diagnosis was 14 days, and time-to-treatment was 57 days. During the pandemic, median time-to-consult significantly increased to 365 days (Mann-Whitney test, U = 589, p = .028), but time-to-diagnosis decreased to 10 days, and time to-treatment decreased to 43 days, although these were not significant (U = 775, p = .667; U = 809, p = .917). Among the 81 patients in the study, 14 (17.28%) showed tumor progression (pre-pandemic: 6; 15%; pandemic: 8; 19.51%), but there was no significant association between time-to-consult and increase in clinical staging for both pre-pandemic (χ2(38) = 34.2, p = .646) and pandemic groups (χ2(16) = 23.1, p = .110) or between time-to-diagnosis and increase in clinical staging for pre-pandemic (χ2(56) = 36.8, p = .978) and pandemic groups (χ2(23) = 28.3, p = .267). Overall, there was no significant association between time-to-treatment and increase in clinical staging for both pre-pandemic (χ2(62) = 80.00, p = .062) and pandemic groups (χ2(32) = 30.4, p = .548), but a subset of patients with larynx primary tumor site had a statistically significant association between time-to-treatment and tumor progression (χ2(5) = 12.00, p = .035).

Conclusion:This study revealed that there was an increase in time to-consult for head and neck cancer patients during the pandemic. However, there was no significant difference in time-to-diagnosis and time-to-treatment. This shows that the Department of ORL-HNS, East Avenue Medical Center has provided pandemic head and neck cancer care similar to before the pandemic. No significant associations were found between tumor progression and time intervals of the key clinical time points but patients who had an increase in clinical stage were noted with longer time-to treatment. It was also observed that more patients were in advanced clinical stages during the pandemic.

Periocular Measurements Among Filipino Adult Employees of Dr. Paulino J Garcia Memorial Research and Medical Center

Arjay Franz Joseph A. Alberto, MD, Ronaldo G. Soriano, MD — Tue, 28 May 2024 00:00:00 -0700

Objective:To determine the normative values of interpupillary distance (IPD), intercanthal distance (ICD), outer canthal distance (OCD), and palpebral fissure length (PFL) among a sample of Filipino adults.

Methods:

Design: Cross-Sectional Study
Setting: Tertiary Government Training Hospital
Participants: 300 Filipino hospital employees aged 19 to 65 years old

Results: Out of 300 participants, 156 (52%) were men and 144 (48%) were women. The mean IPD was significantly different t(296) = 12.89, p = .00001 between males (62.59mm; SD 1.65) and females (60.29mm; SD 2.07). The mean ICD was significantly higher among males (34.91mm; SD = 1.37) than females (31.19mm; SD = 1.52); t(288) = 9.58, p = .00001. Men had a significantly higher mean OCD (93.05mm; SD 4.14) than women (91.31mm; SD = 3.97); t(298) = 3.73, p = .0002. The PFL was significantly broader among men (32.60mm; SD = 1.25) than women (31.05mm; SD = 0.99);t(291), = 11.96, p = .00001.

Conclusion: Our study determined normative values of IPD, ICD, OCD and PFL among a sample of Filipino adults. We found a sexual dimorphism with men having significantly higher values than women.

DokNet’s World

William U. Billones, MD — Tue, 28 May 2024 00:00:00 -0700

Mandibular Fracture in a Newborn From Birth Trauma: A Case Report

Tue, 28 May 2024 00:00:00 -0700

Objective: To report a case of mandibular fracture in a newborn presenting with post-delivery oral cavity bleeding and to discuss its etiology, clinical findings, diagnosis, management and outcome after treatment.

Methods:

Design: Case Report

Setting: Tertiary Government Training Hospital

Patient: One

Results: A newborn girl was referred for oral cavity bleeding after partial breech extraction. An intraoral hematoma and symphyseal step deformity on examination corresponded to a complete
fracture of the symphysis and downward displacement of the left hemimandible on facial CT scans with 3D reconstruction. An uneventful closed reduction with external fixation using acrylic cap splint with circum-mandibular wiring was performed under general anesthesia and she was discharged feeding well. The cap splint and wires were removed after 4 weeks showing good facial symmetry and bone alignment. There were no complications on follow-up after 1 year.

Conclusion: Mandibular fracture can result from traumatic delivery and present with oral bleeding and hematoma. A thorough physical examination and workup should be done to assess for the sites involved. A multidisciplinary approach should be undertaken to provide the best possible care with the least invasive technique.

Warthin-like Variant of Mucoepidermoid Carcinoma of the Parotid Gland

Tue, 28 May 2024 00:00:00 -0700

A 57-year-old woman with a 2-year history of a left infra-auricular mass with no associated symptoms presented with a 6.0 cm ´ 4.0 cm ´ 3.0 cm firm, non-tender, movable mass. No imaging was done. Fine needle aspiration biopsy (FNAB) revealed sheets of epithelial cells that had abundant dense grayish-blue cytoplasm in a mucinous background with abundant lymphocytes (Figure 1), suggestive of salivary gland neoplasm with oncocytic or oncocytoid features (Category IVB, Salivary Gland Neoplasm of Uncertain Malignant Potential).¹

Total parotidectomy revealed a 4.3 X 3.2 X 3.0 cm deep lobe lesion with a tan-grey to dark brown, smooth and dull external surface. Cut sections showed a cream-white to pink, lobulated, heterogenous cut surfaces. Microscopically, the lesion was unencapsulated with poorly demarcated borders. The neoplastic cells were arranged in haphazard sheets and surrounded by abundant lymphocytes. The tumor cells had abundant eosinophilic and granular cytoplasm compatible with oncocytes with mild to moderate nuclear atypia. There were occasional cystic spaces that contained mucin though mucocytes were not readily apparent. (Figure 2) Necrosis, perineural and lymphovascular space invasion or anaplasia were not evident.

Reflections on Retirement: The Sunset Can be Spooktacular!

José Florencio F. Lapeña, Jr., MA, MD — Tue, 28 May 2024 00:00:00 -0700

Where are we headed, oh, where have we gone?

We’ve come a long way, now, let us move on.

Dreams are for dreaming, wake up and they run,

Life is for living, come, let us move on.¹

¹JF Lapena, Moving on

Retirement (n.); from French retirement (1570’s); retire + ment.

Retire (v.) 1530s, of armies, “to retreat, draw back,” also, of persons,

“to withdraw” to some place, especially for the sake of privacy; from

French retirer – from re- “back” + tirer “to draw” and -ment; common

suffix of Latin origin; came to be used as a formative in nouns of

action in Vulgar Latin and Old French. The sense of “leave one’s

business or occupation” is by 1660s.²

²Online Etymology Dictionary

https://www.etymonline.com/word/retirement

Congenital Unilateral Hearing Loss from Cochlear Nerve Canal Stenosis

Nathaniel W. Yang, MD — Tue, 28 May 2024 00:00:00 -0700

A 2-month-old baby girl presented with a failed neonatal otoacoustic emission (OAE) hearing screening in the left ear. Combined Auditory Brainstem Response/Auditory Steady-State Response (ABR/ASSR) testing confirmed the presence of a unilateral left moderate to severe hearing loss. No Joint Committee on Infant Hearing (JCIH) risk factors for early childhood hearing loss¹ were identified. She subsequently underwent computed tomography (CT) of the temporal bones to determine the presence of any inner ear malformation. No abnormalities of the internal auditory canal, cochlea, semicircular canals and ossicles were noted by the radiologist, and the study was officially reported as a “normal temporal bone CT scan.”

Independent review of the CT imaging revealed the presence of a visually apparent disparity in the width of the cochlear nerve canals. (Figure 1) Measurement of the cochlear nerve canal width in the axial plane parallel to the infraorbitomeatal line² using the length measurement tool in the DICOM imaging software (RadiAnt DICOM Viewer, Version 2024.1, Medixant) indicated a cochlear nerve canal width of 2.18 mm on the right and 1.02 mm on the left. (Figure 2) Applying the suggested cutoff point of 1.2 mm as described by Lin et al.,² we identified the presence of left cochlear nerve canal stenosis as the etiology of the congenital unilateral hearing loss.

The cochlear nerve canal, which has also been referred to as the bony canal for the cochlear nerve (BCNC), cochlear aperture, and cochlear fosette, is the bony transition point between the internal auditory canal and the cochlear modiolus. A relationship between a hypoplastic cochlear nerve canal and congenital sensorineural hearing loss was first suggested by Fatterpekar et al. in 2000.³ Subsequent studies confirmed the association between cochlear nerve canal stenosis and sensorineural hearing loss that ranges from near-normal to profound, with a statistically significant relationship between the degree of hearing loss and the degree of stenosis.⁴

Various cutoff points to define stenosis of the cochlear nerve canal have been identified in the medical literature. These cutoff points range from 1.2 mm to 1.7 mm when the canal width is measured in the axial plane.² This particular case demonstrated clear-cut evidence of cochlear nerve canal stenosis, as it satisfied the smallest cutoff criteria (< 1.2 mm) seen in the medical literature.

The identification of cochlear nerve canal stenosis as the cause of congenital sensorineural hearing loss is important not only from a diagnostic point, but also from a prognostic perspective. Cochlear nerve deficiency has been noted to be highly prevalent among pediatric patients with cochlear nerve canal stenosis,⁵ and this has significant negative implications in relation to rehabilitation with external hearing devices and cochlear implants.

Contents Vol. 39 No. 1 January-June 2024

Philip J Otolaryngol Head Neck Surg — Tue, 28 May 2024 00:00:00 -0700

EDITORIAL

Reflections on Retirement: The Sunset Can be
Spooktacular!

Lapeña JFF

ORIGINAL ARTICLES

Computed Tomography Analysis of the Anterior
Epitympanic Recess and Sinus Tympani Depths
Among Filipino Adults at the De La Salle University
Medical Center

Gutierrez GTL

Prevalence of and Risk Factors Associated with
Methicillin-Resistant Staphylococcus aureus (MRSA)
Carriage Among Cutting Specialties at the Ospital ng
Maynila Medical Center

Monteverde MRQ, Alcira RCV

Determination of the Relationship Between Olfactory
Function Threshold and Quality of Life Among Adult
Filipinos with Perceived Olfactory Dysfunction

Abaya MYB, Ang-Capuno KCF, Regalado-Go JAF,
Gansatao FM, Onofre-Telan RDC, Gelera JE

Clinicodemographic Profile and Treatment Outcomes
of Patients with Upper Aerodigestive Tract Foreign
Bodies in the Southern Philippines Medical Center:
A Five-Year Retrospective Review

Tagsa, JMP, Segocio, DJD

Clinical Care Pathway Time Intervals and Tumor
Progression Among Head and Neck Cancer Patients
at East Avenue Medical Center Before and During
the COVID-19 Pandemic

Rafanan FMJ, Alfanta EM, Instrella RRPA

Periocular Measurements Among Filipino Adult
Employees of Dr. Paulino J Garcia Memorial Research
and Medical Center

Alberto AFJA, Soriano RG, Aragaon MC

CASE REPORT

Mandibular Fracture in a Newborn From Birth Trauma:
A Case Report

Ablay IPG, Yambot KKK, Peñaflor NAI

SURGICAL INNOVATIONS AND INSTRUMENTATION

A Prototype 3D Printed Suction Port Adapter for a
Wireless Otoendoscope

Garcia MCZ, Amable JPM

FEATURED GRAND ROUNDS

Synchronous Primary Head and Neck Tumors:
Follicular Thyroid Carcinoma and Squamous
Cell Carcinoma of The Tonsil

Maristela PB, Cruz ETS

FROM THE VIEWBOX

Congenital Unilateral Hearing Loss from Cochlear
Nerve Canal Stenosis

Yang NW

UNDER THE MICROSCOPE

Warthin-like Variant of Mucoepidermoid Carcinoma
of the Parotid Gland

Curso KAJ, Reyes JCB, Rivera JP, Carnate JM

CAPTOONS

DokNet’s World

Billones WU