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:_,_#=_._._ :_st_._w s, Jwe.'llail 2512, 25/..%_._ta¢.=(.9_;_,_,so.,,_ o._.,_=, e_,.,_,_ e_Ed..: 633.2783, 633-8344, P920-9(/6-6652e,_ wo.: _l_tt4_x_ . ¢rt_IL_ACKNOWLEDGEMENTThe editorial staff of the Philippine Journal of Otolaryngology-Head & Neck Surgeryappreciates the full support and assistance given by Solvay Pharma Inc., Phils. Without whichthis would not have been possible and Ms. Arlene Sayson for facilitating everything; Ms.Johanna C. Mendoza for typing the manuscript and Dr. Jose Florencio F_ Lapefia, Jr. for theeditorial assistance.

from neutrophils. In most cases, the tree, that it has the same effects on nasalproteases are blocked by inhibitors, and mucociliary clearance. Therefore, it i_sinflammation remits and is cured. If the recommended that further studies be doneactivity of proteases exceeds that of regardingthe direct influences of smokinginhibitors,the mucosa of the host may be on nasal mucociliarytransportactivity. It isdamaged and facilitate fluid secretion. In hoped that a better understandingof thegeneral, the rheologic properties of this destructivechanges caused by smokingonsecretionare far from optimumfor transportby mucociliary function, and mucociliarythe nasal epithelium and its mucociliaryfunctionwill lead to conclusiveevidenceontransport is further impaired by nasal the effect of smokingon the developmentofmucosal changes. Since the ostium of nasal and paranasal sinus diseases as wellparanasal sinuses is narrowed in chronicsinusitis, stagnation and accumulation ofas malignancies.fluid occurs. Stagnated fluid is easilyinfected, and this is followed by BIBLIOGRAPHYinflammation.This repetition of reinfectioninducedinflammation as well as the 1. Bhide, S.V. et al, " Studies on tobacco specificmaintenance of inflammation by mediators nitrosamines and other carcinogenic agents insmokeless tobacco products." Tobacco andare considered serious problems. Thus, the Health: The Indian Scene. UICC workshop, Tataabove mechanism was proposed for the Memorial Center, Bombay, 1989.pathogenesis of chronic sinusitis: a vicious 2. Burgersdijk, F. et al. Testing Ciliary Activity incycle of self-mediated inflammation which Patients with Chronic and Recurrent Infection ofmay be induced by smoking, the Upper Airways: Experiences in 68Laryngoscope. 96:1029_1033, Sept. 1g86.Cases.Explaining to patients the effects of3. Chetan, S. "Nasal Mucociliary Clearance in SnuffUsers." J- LaryngoI-Otol. 107 (1): 24-26, Jan.smoking on nasal mucociliary clearance, 1993.therefore, can prevent the vicious cycle 4. Chiba, M. and Masironi, R. "Toxic and TraceElements in Tobacco and Tobacco Smoke". Bullinitiatedby mucociliary dysfunction. Aside World-Health-Organ. 70 (2: 269-275, 1992.from the basic methods of treatment 5. Dalhamn, T. "Effect of Cigarette Smoke on Ciliaryconsistingof administrationof antibiotics,if Activity." Am-Rev-Resp-Dis. 93:108-114, 1966.indicated, drainage, administrationof anti- 6. Dawson-Saunders, B. and Trapp, R.S. Basic andClinical Biotatitis. 2rid ed. Illinois: Prentice-Hallinflammatory agents, and ventilatory International Inc., Aug. 1993.support, physiciansmust also advise their 7. Jaffe, J.H. " Drug Addiction and Drug Abuse."patientsto stop, if not, minimize cigarette Goodman and Gilmans, The Pharmaceutical Basisof Therapeutics. 8th ed. New York: Pergamonsmoking due to its ill effect on mucociliary Press, 1990.clearance. 8. Kensler, C.J. and Battista, S.P. "Componellts ofCigarette Smoke with Ciliary Depressant Activity."New Engl j Mad. 26g (22):1161-1166, Nov. 1963.CONCLUSION g. Lindberg, S. and Runer, T. " Method for In-VivoMeasure_nent of Mucociliary Activityinthe Human Nose. "Ann-OtoI-RhinoI-Laryngol.It has been demonstrated in this 103(7)-558-566, Ju1.1994.study using saccharin test that cigarette lo. Liote, H, et al, "Role of Mucus and Cilia in NasalMucociliary Clearance of Healthy Subjects," Am-Jsmokingcauses a delay in the nasal Respir-Crit-Care-Med. 150 (1): 66-71, Jul. 1994.mucociliary clearance. It is likely to be 11. Muutinen, J, et al. "Ciliary Beating Frequency insecondary to the components of cigarette Chronic Sinusitis." Arch Otolaryngol Head Necksmoke which are noted to be ciliary Surg. 119: 645-647, June, 1993.depressants. 12. Rayner, C. et al. "Ciliary Disorientation in Patientswith Chronic Upper Respiratory TractInflammation."Am-J-Respir-Critcare-Med.151:800-804,1995.RECOMMENDATION 13. Regnis, J. at al. "Mucociliary Clearance in Patientswith Cystic Fibrosis and in Normal Subjects. = Am-J-Respir-Crit_Care-Med. 150 (1): 66-71 ,July 1994.The present study can only 14. Sakakura, Y. et al. "Nasal Mucocillary Transportdemonstratethe effect of smoking on theof Chronic Sinusitis in Children." Arch-Otolaryngolnasalmucociliary clearance among Head-Neck-Surg. 118: 1234-1237, Nov. 1992.smokers. The precise and directmechanisms by which smoking influencesnasal mucociliary clearance rates remainunanswered. Presumptions were made,based on the effect of smoking onmuc0ciUaryactivity of the tracheobronchial

a new name for this syndrome and its Sphenoid Encephalocele Journal ofprecipitating insult This being the first case Neurosurgery 1992 77 (6) 949-951of an imperforate oral cavity reported in the 4 Weckx LL, Justino DA, Guedes ZC,Philippines, there is understandably a lack Weckx LY Hypoglossia Congenitalof literature both local and foreign It is, Ear, Nose and Throat Journal, 1990 69therefore, proposed that physicians (2) 108-111.regardless of their specialties, report 5. Lalwani AK, Engel TL. Teratoma of thecongenital defects with possible associated Tongue: A Case Report and Review ofprenatal insults. This will create a wealth of the Literature. International Journal ofstudy material for establishment of a more Pediatric Otolaryngology. 1992 24 (3)definitive means of diagnosis and 261-268.management. 6. Kalant H, Rochslau WILE. ChemicalTeratogenesis.Principles of MedicalPharmacology. Fifth Edition.1989 645-BIBLIOGRAPHY 650.7. Beatty E. Embryology of the Head and1. Friend GW, Harris EF, Mincer HH, Fong Neck. Textbook of Plastic, MaxillofacialTL, Carruth KR, Oral Anomalies in the and Reconstructive Surgery. SecondNeonate, by Race and Gender, in an Edition. 1992 271-277.urban Setting. Pediatric Dentistry. 1990 8. Huffman JW, Dewhurst CJ, Capraro VJ.12(3) 157-161. The Gynecology of Childhood and2. Gartlan MG, Davis J. Smith RJ. Adolescence. 1981 156-159Congenital Oral Synecchiae. Annals of 9. Wentz AC. Congenital Anomalies andOtology, Rhinology and Laryngology. Intersexuality. Novaks Textbook of1993 102.186-187, Gynecology. Eleventh Edition 140-141.3. Itakura T, Miyamoto K, Uematsu Y, 10. Nelson WE, Vaughan III VC. TextbookHayashi S, Komai N. Bilateral Morning of Pediatrics. 14th Edition. 1486-1488.Glory Syndrome Associated with

NASAL AND PARANASAL SINUS PROFILEAMONG FILIPINO ASTHMATICS*ALEJANDRO SY, M.D.**BERNARDITO BARRIENTOS, M.D.**VICTOR JOHN LAGMAN, M.D. **FRANCIS V. ROASA, M.D.**ABSTRACTThe association between asthma and concomitant rhinitis and sinusitis has beenrecognized since the early part of the century and has been reconfirmed in children and adult.Sixty five Filipino asthmatic patients were included in this study. Their nasal and respiratorysymptoms were evaluated using a set of questionnaires with visual analogue scales.History taking and otorhinolaryngologic examination were performed to differentiatebetween allergic versus no allergic conditions. Nasal endoscopy revealed that the middleturbinate was commonly affected An abnormal Waters' view x-ray was present in 86%. Theevaluation of asthmatic patients in the present investigation was designed to obtain basic data toassess the nasal and paranasal profile among Filipino asthmatics. To manage these patients,one must recognize and treat the factors that initiate, aggravate, and perpetuate thebronchospatic state.Keywords: Asthma, rhinosinusitis, allergyINTRODUCTIONIt is well established that the upper relationship between nasal disease andand lower airways are pathophysiologically lower airway hyperactivity; and to establishrelated. Recent publications correlate nasal an anatomic trend with clinical correlationsand paranasal sinus disease with lower on the nasal and paranasal sinuses amongairway disease, particulady asthma.Filipino asthmatics.In a study made by the AmericanNational Institute of Allergy and InfectiousMATERIALS & METHODSDisease, non-rhinologically orientedphysicians failed to accurately delineate Sixty five Filipinos diagnosed toover 50% of nasal and paranasal conditions, have asthma and are presently members ofMore are probably unaware of the myriad the Asthmatic Foundation of the Philippinesrhinologic conditions which can trigger were included in the study. Subjects wererecurrent and refractory asthmatic seen on two occasions during the regularsymptoms. It is in the light of such meeting of the group in February and Marchcomplaints that this study was conceived,of 1993. The age range was 15 to 71 years.Therewere 38 females and 27 males.The objectives of this study is toevaluate the relationship between asthmaticComplete histories were taken andpatients and their nasal and paranasal otolaryngologic examinations performed toconditions by describing the nasal and differentiate between allergic and nonparanasalprofile of Filipino asthmatic with allergic rhinitis. Characteristics such as ageregards to history, nasal endoscopy and and sex, history of other atopic diseases,Water's view x-ray; to determine the family history of allergies, presence of" Presentedin DescriptiveResearchContestOctober 27, 1995,Holiday Inn Hotel, Manila**Resiaent, Department of Otorhinolaryngology, Sto,Tomas UniversityHospital***Consultant, Department of Otorhinolaryngology,Sto.Tomas University Hospital

stress, anxiety and other environmental Nasal endoscopic examinationfactors and use of medications were noted, revealed that the middle turbinates wereExcluded were smokers and those who commonly affected with polypoid mucosa.were habituatedtotopicaldecongestants.Eight (12.3%) patients had nasal polypswhile 7 (11%) patients had septal deviation.A questionnaire was used to assess Four (6%) of the patients had normalpresent and past respiratory complaints, endoscopic examination. Of these 2 hadThe probable causes of their nasal negative Water's view x-ray and 2 hadsymptoms and asthmatic attacks, the time of bilateral maxillary sinusitis.the day and season when the symptomsoccurred, and the treatment they got were Polysinusitis was seen in 25 (39%)also probed. Likewise, a visual analogue patients, pansinusitis in 19 (29%) patients,score sheet was used to grade nasal bilateral maxillary sinusitis in 11 (17%),complaints, the scale was from 0 to 10 cms. unilateral maxillary sinusitis in 1 (1%). Nine(0=no symptoms; 10=very bad), (Royal (14%) patients had normalx-ray results.Brompton Nose Clinic in London).Nasal endoscopic examination wasDISCUSSIONperformed after intranasal instillationof 4%xylocaine and oxymetazoline(1:1 dilution) The nose regulates air flowmixture over both nasal cavities. A 30 resistance in series with the tracheodegreeHopkins Storz telescope was used. bronchial tree, and, because of this,The following categories of abnormalities alterations in nasal function could havewere assessed: (1) structural abnormalities direct and/or reflex effects on lower airwaywere defined as deformities of the bony performance. The caliber of the nose andskeleton or cartilaginousskeleton (or both) intrathoracicairways can be altered by bothof the nose, includingthe septum, lateral humoral stimuli and neural reflexes, andnasal walls, upper lateral cartilages (roof, there is some suggestionthat patientswithcartilages), Iobular cartilage, soft tissue respiratory disease may respond differentlyscars and synechiae, (2) mucosal than normal subjects to exercise, cold airabnormalities were defined as disorders of and inhaled pollutants. Mechanical orthe nasal mucosal lining, and (3) mixed chemical irritation of the nose results inabnormalities were defined as abnormalities bronchoconstriction especially in patientsthat involved both the nasal skeleton and the with combined asthma and allergic rhinitis.mucosal lining. All endoscopic findings were These observations are supported by thenoted in nasal endoscopyexamination forms high incidence of coexisting rhinitis a,nddeveloped by Jorgensen.sinusitis in patients with bronchial asthma.Water's view were taken on all Although both rhinitis and asthmapatients and the films were evaluated can occur without a recognized allergicindependently by the authors and two mechanism, IgE mediated inflammation is aradiologists without knowledge of the major pathway. A survey of 1,100 allergypatients' clinical status. Radiologic patients done by Smith, et.al, found thatabnormalitieswere classified according to 78% of patientswith extrinsic asthma hadpresence of opacification of the sinuses; concomitant nasal allergy symptoms whilepresence of mucoperiostealthickeningand 38% patients with allergic rhinitis hadconditionofthe bonywalls, episodes of asthma. Rackeman andEdwards found that approximately 20% ofpatients with allergic rhinitis subsequentlyRESULTSdevelopedasthma.Of the 65 patients,45 (69%) had apositive history of atopy. Three most Based on the present day conceptscommon complaintswere sneezing (mean of the pathogenesis of bronchial asthma,score of 6.6), followed by anterior nasal three mechanismsby whichparanasalsinusdischarge (5.8) and nasal obstruction(5.6). disease could produce bronchial asthmaEpistaxis was the least common symptom seem particularly plausible include: 1)(0.76). Most patients had nasal and Bacterial seeding of the lung withparanasal complaints prior to asthmatic pansinobronchitiswith resultant wheezing.attacks.2) Reflex bronchospasm from nasal stimuli

carried by the trigeminal nerve to the 4. Forysth Rd, Cole PS, Shepard RJ:parasympathetic fibers of the 3) Exercise in nasal patency, J.AllergyEnhancement of B-adregenic blockade by 41:269, 1984.sinusitis. 5. Mygind N: Nasal Allergy, ed 2 Oxford,1979, Blackwell Scientific Publications,The frequent occurrence of polypoid pp 1-363.turbinates and abnormal Waters view 6. Deal EC Jr, McFadden ER Jr, Ingramamong our patients conform with RH Jr, Breslin FJ, Jaegger JJ: Airwayobservations made by other authors, responsiveness to cold air and exercisein normal subjects and those with hayfever and asthma. Amer. Rev. RespirCONCLUSION Dis, 121:621, 1980.7. Drettner B.: PathophysiologicalIn this study, the authors combined Relationships between Upper andanamnesis and physical examination with Lower airways, Ann Otol Rhinolnasal endoscopic and roentgenographic Laryngol 79:499, 1970.examinations to establish the presence of 8. McFadden ER: Nasal-sinus-pulmonaryallergy and paranasal disease among reflexes and bronchial asthma, J ofFilipinos asthmatics. Most patients had a Allergy and Clin Irnmunol 78:1, 1986.history of nasal and paranasal complaints 9. Sluder G: Asthma as a Nasal Reflex,prior to exacerbation of asthmatic attacks. JAMA 73:589, 1919.The middle turbinates were commonly 10. Slavin RG, Cannon RE, Friedman WH,affected with mucisal polypoid degeneration, Plaitang E, Sunaram M: Sinusitis andsome presented with nasal polyps and bronchial asthma, J allergy Clinseptal deviation. Immunol 66: 250, 1980_11. Kaufman J, Wright GW: The effect ofSince a significant number of nasal and nasopharyngeal irritation onpatients with rhinitis and sinusitis will go on airway resistance in man. Amer Revto develop asthma, it is recommended that Respir Dis 100:626, 1969.clinicians properly diagnose and treat nasal 12. Settipane GA, Chafee FH: Nasal Polypsabnormalities that may become more in asthma and rhinitis. J Allergy Clinprominent and problematic over the years. Immunol 59:1, 1977.Successful care of asthmatic based on 13. Braman SS, Barrows AA, De Cotis BA,appropriate medical management should be Settipane GA, Corrao WM: Airwaya team approach, hyperresponsiveness in allergic rhinitis -A risk factor for asthma, CHEST 91:5,1987.BIBLIOGRAPHY 14. Broder et.al,: The epidemic of asthmaand hay fever in a total community,1. Kaliner M, Egglestons Pa, Matthews KP: Tecumesh, J Allergy 33: 524, 1962.Rhinitis and Asthma, JAMA 358,1987. 15_ Friedman R, Ackerman M, Wald E,2. Jorgensen RA: Endoscopic and Casselbrant M, Friday G, Fireman P:Computed Tomographic Findings in Asthma and bacterial sinusitis inOsteomeatal Sinus disease. Arch children. J Allergy Clin Immuno 74:2Otolaryngol Head & Neck Surgery 117: 1984.279, 1991. 16. Berman SZ, Mathison DA, Stevenson3. Rachelefsky GS, Katz RM, Siegel DD, Usselman JA, Shore S, Tan EM:SC:Chronic sinus disease with Maxillary sinusitis and bronchial asthma:associated airway disease. Chest 86:9, Correlation of roetgenograms, cultures1984. and thermograms. J Allergy ClinImmunol 53: 5, 1974.

VISUAL ANALOGUE SCORE (IN CENTIMETER)Pakent Age SeK N_sal Er_osc_py E._m ,_mi¢ Ntmal Pmi=_ms '_lVo neX Nas_d Nasat _,tO_Ve_Badt Itchines_o__e _ Xn'__,_Fav_y _"k_ 1_ _ Dischiirg_ Olscl'_q3e F.,pL_a_s Faciat He_d. Nose Throat Ea_ (VCateds, _ew)Hisk_ S,",eP-_rt_ Anl Pos_ I=_n aches_1 51 F Gt-arlcdarChan_s MiddleTurl_nates Posi_'._e 6.0 5.8 6.2 5.2 4.0 4.5 0.0 6 5 0.0 6.6 8.0 Pol)_sinulsi_s2 28 F Pul_poidIt'Jl=tlurTurbinates Postk_ 5.9 5.g 6.8 6.0 8.6 8.0 6.2 7.5 6.g 6 5 7.+ _ -'_.-.-_ t_l_d_m_/_nu_s3 27 F Poh/_d ;,,;_Ju_. TutI_,_.=_ p OS_[_ve 0.2 6,2 ?,0 5.9 6.8 0.0 0.0 0,6 3.3 4, 5 4.9 P_s_m.l_§S4 41 F P,._l=U;_; _,_._,=T='t_,,_t©=;...tara; De_ a'_e Ne_at_ 3.3 3.3 3.8 10.0 5.0 0.5 0.0 10.0 5.7 5.7 5.6 Ne_atb_5 42 F P..;,vpoM MKlldleT_'L_,.tu s;.Sa_l Spur Negative 7.0 7.0 10.0 10.0 10.0 0.0 0.0 0.0 1.0 1.0 0.0 Po_inusi5s6 15 M Paradox_al_ Bent R. Midge Turbinntes:Sepal Spur posi_ve 2.0 2.6 5.0 5.9 0.0 0.0 0.0 5.9 5.0 5.9 0.0 Po_jsinusNs7 16 M Ea_r_;_.y t,l_,,.I Pos_ve 5.8 5.8 0.0 0.0 O.0 0.0 0.0 5.7 5.5 5.5 5.5 B_lalecalMmdla_ S_nLm_s6 29 M Pol_x_d _,JcE¢ Tmbinates;_ Sp_.I Pos=l_v_ 0.0 10.0 0.0 4.4 4.6 4.4 4.5 4.5 4.5 0.0 0.0 Plm_dnL=si6s9 31 M Pol_0o_d,=__'= Tur_r_¢_; I=_'ado]d=a_ BeN MiddleTud_at=tes Nega_e 6.0 6.Q 6.1 6.I 6.3 (__ 6.0 5.g 0.0 2.5 6._ Pa_sinu_s10 29 F S_; Devmtion posilive 5.0 3.7 10.0 10.0 10,0 O.0 0.0 10.0 10,0 7,4 7.4 Pol_'sinudlis11 15 F C_.G= i_dto_a, SeldatOm_lion Ne_la_iw g.0 0.0 3.7 5.0 0.0 5.2 0.0 6.1 5.3 6.0 0.0 Paun_si_u12 71 F V_lthS_r-Middle T=.t_r=t_s, Pol_oid I_sal MiJcos_ Ne_lid_e 5.6 5.0 4.0 2.3 7.6 0.0 0.0 4.3 5.4 5.5 4.0 Po_at husks13 23 F PoT_id MiddleTur_nttes; Se_at Dmialio_ I:_s_6w 10.0 O.0 10.0 0.0 10.0 0.0 0.0 0.0 5.0 5.0 0.0 Pansinu_s14 32 ;_1._ ;,u_;_;_d;i_. _. T_lt;,_e _ Posd_ve 7.0 8.0 9.0 5.0 7.0 0.O 0.0 3.0 0.0 7.0 0.0 NeBal_ve75 03 M PoP_oid _,_;G=TurbOt, ares PosJive 10.0 0.0 10.0 0.0 10.0 0.n 0.0 0.0 0.0 0.0 10.0 Pa_dnus_is16 52 F _',.;vFu_ Mulberr_ike InferiorTurban=tes positive 0.0 0-0 0.0 0.0 0.0 _.(3 0.0 _0.0 tO.O 1(3.0 0. n Ne_'ive17 18 F I'l_p=l=ul;ad Ihf_nm"Turbinates Positive 6.0 2.1 7.4 7.2 0.8 0.0 0.0 3.0 5.4 3.9 _.0 BJrlderat18 82 M Pol_o_ _,;d._=and b_=_u, T=,b;,,_i_ Po_ 0.0 8.0 3.0 0.0 3.0 0.0 O.0 0.0 2.9 2.9 0+0 Mmd_Pt" --_'--=_--'sP--_-_s1g 31 F Nasat Pol_os Posib_ O.O 7.5 10.0 10.0 0.0 0.O 0.O 10.0 10.0 10,0 0.0 Po_sinus_s20 3_ M _a_ _.;=J;,..i P0_l_Ve 0.0 6.3 6.8 7.8 5.7 O.O 0.0 4.4 4.5 5.5 5.6 Bilab_ralM_dl_ S_nu_l21 15 M Septnt De_a Hoe, Ne_lati_e 10.0 10.0 10,0 10=0 0,0 0.0 10,0 0.0 10,0 10.0 10,0 Pansinum_is22 25 M Po_/poidamd_ Muco_a MiddleT_Oilrate_ Po_i_ve 9.4 5.4 10.0 5._ 10.6 0.0 8.1 8.1 10.0 9.8 0.0 Po_sil';_,s23 32 F _,_,,_ P_J_le r Nazi; Pol_poidand h_:klleTur_[nates P_ 3.8 4.0 4_0 4,0 4,4 0,0 Q.0 7,5 6.2 6,2 e.2 N_ative24 44 F Nasal Po_ps; Pol,_ d MiddleT_ldr_tes PosdSve 5,5 5,6 5,6 5.6 5 7 0,0 0.0 4.5 5=5 8,8 5.5 Po_sinusilis25 25 M _oblceous Mu_L_r_ke Irffe_k_Turbinat_s New,ath_e 4,2 2,5 4,2 2.5 4,8 0.0 0.0 3.4 2,0 2,3 6,5 Po_int_sil_s26 28 F E=_ _=_ Normal Posiliv_ 3.9 2,9 1,0 g.5 g,2 0.0 0,0 2,4 0,0 4.6 0,0 Na|laU_27 61 M _+%_=.Titke _nor T_L_.=t_; Po_poid_id_le T_lr_T_ates PosE_ 5.0 2.8 6.6 4.4 3._ 0.0 2.5 2.3 6.4 4.5 0.0 Pol)rs_nusi_s28 51 M GranularMlucosaMidge Turbir_tes Pc_it_ve 3,9 0=0 3,0 3,1 5,5 3,0 0,0 7,4 0.0 10,0 0.0 P_dnusNs29 18 F 7_i¢_=.©_;Mucosa M_ddleTud_inntes Ne_labve 0,0 0,0 5.1 0,0 0,0 0,0 0.0 0,0 0=0 0,0 0.0 Pansinusi8s30 lg M "_,;_-J_r,="M¢l¢osaMid

NASAL MUCOCILIARY CLEARANCE:ITS STATUS AMONG SMOKERS AND NONSMOKERS*MELIZA A. SOTELO, M.D.**ROANNIE CANDIDA A. IBARRA, M.D.**FRANCISCO A. VICTORIA, M,D.***EDGARDO C. RODRIQUEZ, JR_, M.D.***ABSTRACTThe inhibitory effects of smoking on mucociliary clearance of the tracheobronchial treehas been well documented. However, limited information is available for its effect on nasalmucociliary clearance; hence the reason for this study. A group of 30 healthy nonsmokers(controls) and a group of 30 smokers was investigated in a government hospital betweenOctober, 1994 to October, 1995. Using the saccharin method, a significant delay in mucociliaryclearance was found among smokers as compared to the" nonsmokers. The mean nasalmucociliary clearance was 26.37 +/- 5.61 minutes in smokers compared with that of nonsmokers,9.53 +/- 4.08 minutes.Keywords: Mucociliary clearance, saccharin method, smokingINTRODUCTION smokers and nonsmokers. Hilding and morerecently Falk et al and Guilerm, Badre, andNasal mucociliary clearance is the Vignon reported that cigarette smoke is afirst line of defense of the respiratory system potent inhibitor of ciliary transport activity.against inhaled particles. Foreign Kensler et al described a quantitativemicrobodies in inspired air are entrapped in method of studying the effect of repeatedthe mucus blanket of the airway mucosa and short term exposure to gases and aerosolstranspoded with mucus by ciliary activity to mammalian ciliary transport activity.the pharynx. This mucociliary transport Cigarette smoke was found to inhibit thisfunction is one of the most important and transport activity. The bulk of the ciliaryindispensable protective mechanisms of the depressant action action of cigarette smokeairway against the atmospheric was found to reside in the gas phase ratherenvironment, than the particulate phase. Among thevarious components of the gas phaseThis role of the nose as a filter has studied in this system, hydrogen cyanide,today assumed a great importance due to ammonia, formaldehyde, acrolein andthe contamination of the atmosphere with nitrogen dioxide were found to haveinjurious gases and exhaust fumes. These appreciable ciliary depressant activity.pollutants, including cigarette smoke, hasbeen shown to depress mucociliary activity. Being part of the respiratory system,Prolongation of the mucociliary transit time the effect of cigarette smoking on nasalmay predispose an individual to nasal entry mucociliary clearance was assumed to beof virus and/or bacteria. Mucociliary the same as its effect on thedysfunction may then cause deterioration tracheobronchial tree as was describedand perpetuate inflammation of the nose above. However, limited direct informationand paranasal sinuses. It is accompanied by regarding the effect of cigarette smoking onan increased incidence of nasal infections, the ciliary activity of the nasal epithelium isavailable.Several studies have shownsignificant differences in the histopathology This study was undertaken toof the tracheal and bronchial epithelium of correlate the effect of cigarette smoking on"1= Place,PSOHNSAnalyticalResearchContestDecember5, 1995,HotelNikkoManilaGarden,MakatiCity**Resident,Departmentof Otorhinolaryngology, PLM-Ospital ngMaynila***Consultant, DepartmentofOtorhinolaryngology, PLM-Ospital ngMaynila

the mucociliary activity of the nasalepithelium among Filipinos.RESULTSThe nasal mucociliary clearanceSUBJECTS AND METHODS rates ranged from 4.50 to 20.75 minutesamong nonsmokers and from 15.05 to 36.58Thirty chronic smokers, 15 years old minutes among smokers. The mean ratesand above, from both sexes, were included were statistically significant--- 9.53 +/- 4.08in the study. A smoking history of at least 10 minutes among nonsmokers and 26.37 +/-cigarettes per day for a minimum period of 5.61 minutes in smokers --- showing thattwo years was required for inclusion. As a smoking has a significant inhibitory effect oncontrol group, thirty healthy nonsmokers nasal mucociliaryclearance rates.were included in the study. Both groupswere selected from patients seen at Ospitalng Maynila, ENT Outpatient Department, DISCUSSIONfrom October, 1994 to October, 1995. All 60subjects selected did not have any nasal orJaffe in 1990 showed that the actionupper respiratory tract disease in the recent of tobaccQ on the nasal mucosa andpast or during the period of the study; were mucociliary system was due to nicotine andnot given any antibiotics or steroids; and had Iobeline. A similar study made by Bhide et alno congenital, systemic, or metabolic in 1989 showed that a group of compoundsproblems_ known as N - nitrosamines also found intobacco likewise affects the nose and itsComplete history and ENT mucociliary function. The effects of nicotineexamination were done on the subjects, and Iobeline on the nose include theInformed consent was taken from each following:subject prior to the study, Mucociliary 1. An initial increase in quantity of secretionsclearance was measured by the saccharin followed by a prolonged decrease;method of Stanley et al wherein a 1 mm 2. Vasoconstriction of the cavernousdiameter particle of saccharin was placed on sinusoids leading to a reduction in thethe surface of the inferior turbinate 1 cm. swelling of the erectile tissues of the nose;behind its anterior end. The time required 3. Vasoconstriction of the arterioles andfor the subject to experience a sweet taste venules leading to a local ischemia.(saccharin transit time), was measured. Bothnasal cavities were tested for each subject. N-nitrosamines causes a decreaseThe subjects were asked to sit and were in the number of ciliated cells in the nasalinstructed not to sniff, sneeze, smoke, eat or mucosa, damage to the remaining cilia anddrink during the test. Subjects were then metaplasia of columnar cells to cuboidalasked to swallow every 30 seconds and to then to squamous epithelial cells.indicate when the sweet taste wasperceived. If no taste was perceived after 60 Bhide et al (1989) has shown thatminutes, the test was stopped and the ability the purified extracts of the aboveof the patient to taste saccharin placed compounds possess carcinogenic effects indirectly on the tongue was verified. The tests mice. Because of the delayed nasalwere carried out under conditions of room mucociliary clearance, the potentialtemperature and humidity.. All 60 subjects carcinogens remain in contact with the nasalwere tested on two occasions with an mucosa for prolonged periods of time and ininterval of one week between the two tests, greater concentrations. This chronicThe average nasal mucociliary clearance expos'ure of the nasal epithelium to potentialrate was then computed for each subject carcinogens leads to metaplastic changes inand recorded, the cells of the nasal epithelium and tomalignancy.This is a case control study usingstratified sampling of subjects. The average Mucociliary dysfunction sets up anasal mucociliary times of the two study vicious cycle in which the infection-inducedgroups, namely the nonsmokers and accumulation of fluid maintains andsmokers, were calculated and compared aggravates airway inflammation. Bacterialusing the Student's t-test with a confidence infection causes neutrophil accumulation inlimit of +/- 2 S.D. or a p value < 0.05. the nose and paranasal sinuses and leadsto excessive increase in proteases released

4. Cummings, CW, et al. Otolary-ngology- Radiotherapy." int. Journal of RadiationHead & Neck Surgery 2nd ed. St. Louis, Oncology and Biologiocal Physics, vol.Missouri: Mosby-Year Book, Inc., 1993. 21 (6), Nov 1991, pp. 1403-14.5. Hollinshead, WH Anatomy for Surgeons: 16. Johnson, A. "Laryngeal Cancer:The Head and Neck 3rd ed. Variations in Treatment." The Lancet,Philadelphia: Harper and Row vol 344, Oct 24, 1994, pp. 1173-74.Publishers, 1982. 17. Machieu,HF et al. "Carbon Dioxide6. Million, RR and NJ Cassisi. Laser Vaporization in early glotticManagement of Head and Neck Cancer. carcinoma". Archives of Otolaryngology-A Multi-disciplinary Approach 2nd ed. Head & Neck Surgery, vol. 120, AprPhiladelphia: JB Lippincott Co., 1994. 1994, pp. 383-7.7. Stell, PM. Scott-Brown'sOtolaryngology 18. Nakayama, M and JH Bradenburg.5th ed. Laryngology London: "Clinical underestimation of laryngealBuitte_vorths & Co. (publishers), Ltd., cancer." Archives of Otolary-ngology-1987. Head & Neck Surgery, vol. 119, Sept.8. Thawley, SE et al. Comprehensive 1993, pp. 950-57.Management of Head and Neck Tumors 19. Paine, CH and DV Ash."lnterstitialvol 1. Philadelphia: WB Saunders Co., brachytherapy: Past - Present - Future".1987. Int. Journal of Radiation Oncology &Biolgical Physics, vol. 3(5), 1994, pp.JOURNALS: 1059-64.20_ Piccirillo J.F. et al. "New clinical severity9. Bedford, JS. "Sublethal Damage, staging for cancer of the Larynx: FivePotentially Lethal Damage and year Survival Rates" Annals of Otology,Chromosonal Aberrations in Mammalian Rhinology and Laryngology, vol. 103,cells Exposed to Ionizing Radiations". 1994, pp. 83-92.Int. J Radiation Oncology & Biological 21. Sakata K. et al_ "Radiation Therapy inPhysics, vol 21 (6), Nov 1991, pp. 1457- Early glottic Carcinoma: Uni and69. Multivariate Analysis of Prognostic10. Brooks, JP et al. "Twelve cases of glottic Factors Affecting Local Control". Int.carcinoma,in-situ treated by Journal of Radiation Oncology andradiotherapy: An observation on clincial Biological Physics, vol 3(5), 1994, pp.course versus response." The Journal of 1059-64.Laryngology & Otology, vol 107, Nov 22. Shimm, D.S. "Early Stage glottic1993, pp. 1014-16. Carcinomas: Effect of Tumor Location11. Chacko, DC et al. "Definitive Iraddiation and Full-Length Involvement on Localof T1-T4 larynx cancer," Cancer vol 51 Tumor Recurrence After Radiation(6), PP. 994-1000. Therapy". Radiology, vol_ 192, 1994, pp_12. Chert, WC ET AL,"Compadson of 873-5.radiotherapy and surgical results of 23. Smitt, M.C. and D_R. Gofinnet.early glottic cancer: A Retrospective "Radiotherapy for Carcinoma-in-Situ ofanalysis." Journal of the Formosa the Glottic Larynx." int. Journal ofMedical Association, vol 92, 1993, pp, Radiation Oncology and Biological1076-83. Physics, vol. 28(1), 1994, pp. 251-5.13. dickens, WJ et al, "Treatment of early 24. Suit, H and W. Dubois. "The Importancevocal cord carcinoa: A comparison of of Optimal Treatment Planing inapples and apples." Laryngoscopes, vol Radiation Therapy". Int. Journal of93, 1993, pp. 216-19. R_diation Oncology and Biological14. Eckel, HE and WF.Thumfart. "Laser Physics, vol 2196), Nov 1991, pp. 1471-surgery for the treatment of larynx 8.carcinomas: Indications, Techniques 25. Wang, C.C. and J.T. Efdd. "Doesand Preliminary results." Annals of Prolonged Treatment Course AdverselyOtology, Rhinology & Laryngology, vol Affect Local control of Carcinoma of the101, 1992, pp. 113-8. Larynx?"_ Int_ Journal of Radiation15. Hall EJ and DJ Brenner, "The Dose Oncology and Biological Physics, vol.Rate Effect Revisited: Radiological 29(4), 1994, pp. 657-660.Considerations of Importance in

IATROGENIC FACIAL NERVE PALSY SECONDARY TOSTAPEDECTOMY: A CASE REPORT*MARIDARENDV.ARUGAY, M.D.PROF.UGOFISCH,M.D.ABSTRACTA rare case of immediate facial palsy secondaryto stapedectomy is presented. Adehiscentfacial nerve coveringthe oval windowwas mistakenfor a polyp:displacementof polypin the course of the stapedectomyinducedan immediatefacial palsy and a total hearingloss.The facial palsy lasted for four (4) months before explorationand removal of the offendingprosthesiswhich was placed throughthe dehiscent intratympanicportionof the facial nerve.Seventeen (17) cases of post-stapedectomyfacial palsy reported by several authors werereviewed, This case report showsthat a malformed pinna and a conductivehearing loss isalmost always associatedwith an aberrant facial nerve and abnormal middle ear. This paperfurther serves as a reminderto all otologiststhat: (1) the presenceof a congenitalmalformationof the pinna and hearing impairment is most likely an indicator of an abnormal course of thefacial nerve; (2) in case of post-operative facial paralysis, repeated eletroneuronography (ENoG)is necessary to establish the extent of the nerve lesion and the need for revision surgery.Keywords: Aberrant Nerve, Congenital Malformation of the Pinna, Electroneuronography,latrogenic Facial PalsyINTRODUCTIONOBJECTIVESIn this modern era of super I. To present a rare case of facialmicroscopic otologic surgery, iatrogenic palsy secondary to stapedectomy.facial paralysis should be avoided with moreconfidence. The important thing is to take all II. To review the embryology andthe necessary precautions to prevent such a anatomy of the facial nerve inmishap. Thorough knowledge of normal relation to the middle ear ossicles.anatomy and embryology, (as well asvariations from the normal and frankabnormalities of the facial nerve end middleIII. To remind all otologists that:ear) is mandatory for all otologic surgeons. (a) the presence of a congenitalA well taken history and physical malformation of the pinna andexamination is always the most importanthearing impairment are heraldstool for diagnosis. With the armamentaria ofof an abnormal course of facialfacial nerve monitor and repeated nerve;electroneuronography (ENoG) in case of afacial paralysis, the extent of the nerve (b) in case of a facial paralysis,lesion can be established to aid the surgeonrepeated ENoG is necessary toin the decision to do revision surgery. Theestablish the extent of the nervesurgeon should analyze the benefits of thelesion and the need for revisionsurgery for the patient, over and above thesurgery.accompanying risks of the contemplatedprocedure."Research,Departmentof Otolaryngology,UniversityHospitalZurich**ObserverFellow,Departmentof Otolaryngology,University Hospitalof Zurich***Department Head,Departmentof Otolaryngology,UniversityHospitalof Zurich

The development of the stapes and window and demonstrated an indentation inthe facial nerve is intimately related that this area which was probably the prosthesismalformations of one are commonly (Plate Nos. 2-4). In view of these findings,associated with malformations of the other, surgery was carried out as follows: AnBoth the second branchial arch cartilage endaural incision was done after inspectionand the otic capsule play a role in the of the external auditory canal which wasdevelopment of the facial nerve canal, smaller than normal. A tympanomeatal flapFailure of the development of the stapes was created and the external bony canalsuperstructure may allow the facial nerve to was enlarged with a diamond drill until theassume a more inferior position in the malleus became visible. On opening themiddle ear. middle ear, the following findings werenoted • (1) the long process of malleus wasThe appearance of the pinna allows eroded at the region of the prosthesis; (2)one to predict the degree of development of the lenticular process was detached; (3) thethe middle ear. In general, the more Shea all-teflon prosthesis was embedded indeveloped the pinna, the more developed the facial nerve; (4) the facial nerve wasare the ossicles and facial nerve canal. The covering the oval window completelyliterature leaves no doubt that the degree of (Figures 1-3). The prosthesis was thenmicrotia indicates the degree of congenital removed carefully. The facial nerve wasmalformation of the facial nerve. Minor edematous and strangulated at the distalcongenital anomalies of the middle ear entrance of the fallopian canal. Because thewithout atresia maybe associated with an continuity of the facial nerve was preserved,anomalous course of the facial nerve. 4 no attempt was made to expose the ovalwindow to avoid further damage.Mastoidectomy was carried out exposing theREPORT OF A CASE mastoid segment of the facial nerve afteridentifying the stylomastoid foramen. AA 43 year old male was suffering posterior tympanotomy was done to exposefrom a unilateral conductive hearing loss. the tympanic segment of the fallopian canalThe diagnosis of otosclerosis was made and to the geniculate ganglion. Intraoperativestapedectomy was done_ During surgery, a monitoring of the nerve showed that there"polyp" was found covering the oval window, was a minimal nerve activity afterThe "polyp" was carefully wrapped around stimulation with 0.5 m amp. No irritationthe prosthesis after placement. The potential was audible while decompressingassociated anomaly of the stapes arch was the nerve. After decompression, response toobserved, After surgery, there was an 0.5 m amp. stimulation was identical to thatimmediate facial palsy and a total loss of at the beginning of surgery.hearing. The patient was referred forevaluation to this department four (4) REVIEW OFLITERATUREmonths after the stapedectomy.There are few reported cases ofThe physical examination revealed iatrogenic facial nerve palsy secondary toa right microtia, a right endaural scar, and a stapedectomy. Most of these were delayedretracted tympanic membrane with sclerotic in onset and recovery of function occurredareas in the postero-superior quadrant. The within eight (8) weeks.face showed minimal active movement onthe right side. Electroneuronography Table iii & iV shows the report of(IENoG) demonstrated 100% denervation, some authors.The Fisch facial nerve score was 23 points. TABLEM.Diagnosis on admission was "lesion of a REPORTED CASESOF_FACIAL PALSYSECONDARY TOdehiscent facial nerve in the region of the STAPEDEC'rOMYoval window secondary to stapedectomy", .. AUTHOR NO.OFCASES %The MRI scan showed a pathologic Schuknecht (1971 i : Rare(noexactflclure)increased enhancement above the oval AlthaL_$&H .... (19,73 / , 5/?,307 0.2%Causse (1984_L 3/6,724 0.044% 'window in the sagittal plane (Plate No. 1). Wiet&Levine(1984)_.... 2 ..... --"The coronal sections confirmed the He,maD &diglaelmann 4/33 12%increased enhancement above the oval (19_)

EMBRYOLOGY AND ANATOMY OF THE The stapes develop slightly laterMIDDLE EAR AND FACIAL NERVE than the facial nerve, in the early part of thesecond week, the Reichert cartilage or theThe normal development of the second arch first appears. But by this time,facial nerve and the middle ear bones are the horizontal portion of the facial nerve hasintimately related. Table I summarizes the already been established. If intrinsic forceshighlights of their development, occur, the nerve may be displaced anteriorto the stapes and long crus of incus. One orEMBRYOLOGY T_ble, OF FACIAL NERVE ANDboth stapes crura may fail to develop or theMIDDLEEJ_RBONIES crura may be small and the rudimentaryAGEOF .... LAJ_DMARKQFDEVELOPMENT stapes will be hanging free. The long crus ofGESTATION/_V_EKS) .... the incus as well as the manubrium of the2 6_:1CPLACODE;,r_=,,_=r, .... r,eoo,_.,_, malleus may become atrophic, Mere, f..¢i _laR...... or atape_ t,_p,mo_d,,m: developmentanterior displacement or migration of the• =_gh_l_,latertbanfaclaiher'4*)5 facial nerve weh2 branches:main.. facial nerve over the area of stapes,_,.,,o blastema is enough to disrupt normal_horda tympan[6TO_''.I_,"I: _,13d .... dall_formln_lenu._ development of the ossicles resulting in a8 i_(_b_ishedlacation in thetemporalbone;¢orllig..... ,ruct...... tapes, bayrin_hine congenital conductive hearing loss.1o...... Capsule rnastobdbu.f_e,and temporalbonefm¢ialnerve runs deepin thl ¢_Rilagin,)us_'°°'P'°' ........... The intratympanic portion of the20 _s_.i_ca.t.ionof bony Covering25 bOtleCrl¢lOSeathefa_i_l, ne_r_ve ...... facial nerve begins as it enters theBIRTH TO FIR,ST co,repletionof the ossifl(JabOi'l of bonycanal_E_RO_L,PE anterosuperior portion of the middle ear, justIt is worthwhile to note the proximal to the processus cochleariformis.difference between the classic and the The nerve then turns posteriorly to runmodern theory of embryologic development across the middle ear in a slightly obliqueof the middle ear ossicles. (see Tables II.A direction, and interiorly, just above the& ll.B.) articular surface of the head of the stapes.The abrupt change in the direction of theTABLE lI.AEMBRYYOLOGY OFFACIAL NERVE AND nerve upon entering the middle ear is theMIDDLE EARBONE genu of the facial nerve and just proximal toAgeof Landmark ofDevelopment it is the geniculate ganglion. TheGeatat_oo .... intratympanic portion of the nerve is_veek_; ......... enclosed in a thin bony canal which is.... OTICPLACODE;firstapp..... ce ofsecond a,c frequently dehiscent and which is intimately4 fascia-acoustic primordium; _tart of stapesdevelopment {slighty lat_rthan facialnerve) related to the inferior aspect of the surgical56to7 bend .... dallyiorminggenu dome of the vestibule and the inferior8 established _acat.o. inthef_por._bone: surface of the bony horizontal semicircularcontiguous structures: stapes, layrinthine capsule,mastoid b.... canal lateral to the oval window.and temporal bone0 facial nerve runs deep in the cartilaginousot_°oapsu_. ,.. The facial nerve is frequently20 ossification of bon_ coverin 9 _ displaced and uncovered in congenital25 bone encloses the facial nerveBirth to first comp'letion of the ossification of bony canal middle ear malformations. The two mostY.... fhfe "" common anomalies of the facial nerve are:(1) displacement of the nerve and (2) lack ofTab_e,,B bony cover. It is normal for the bony canalDevelopment of Middle Ear Bones of the facial nerve to be partially dehiscentClaasicalTheory above the oval window but, it is abnormal"'aiddleEarBone Oriain for the bony cover to be so completely,.. malleus Mecl_el'scartilacle{first arch) lacking as to allow the tympanic segment ofincus . Mockers cartilage {first arch]stapes Reichert's cartila_le (second arch) the facial nerve to sag against the stapesand obscure the oval window.

9. Causse JB & Causse JR: Technique forOtosclerosis, Am J Otol vol. 5: 392-396, July 1984.Goodhill divided those patients who 1o. Wiet R & Levine T: latrogenic facial paralysis.Proceedings of the Fifth international Symposium onhave facial paralysis after stapedectomyinto three categories:(1) temporary paresis,the Facial Nerve, Sept 3_6, 1984, Bordeux, France.which is more common and is immediate edited by Portmann; Masson Pub., U.S.A., inc.after operation. This may be due to 11. Fisch U. Panel Discussion No. 14: latrogenic facialpalsy. Proceedings of the Third Internationalinvasion of the anesthesia affecting the Symposium on the Facial Nerve, Sept 3-6 1984,tympanic, horizontal or genu areas. This Bordeux, France. edited by Portmann; Masson Pub.,paresis usually resolve in a few. History U.S.A.,Inc_and a thorough physical examination of the 12. Wiet, Davis, & Shambaugh Jr., latrogenic facialear as microtia, accessory digits, pre- paralysis: prevention and management, "Disordersof the Facial Nerve" edited by Grahm House,auricular tags, etc. should alert the surgeon Raven Press, New York, 1982.of an aberrant facial nerve and middle ear 13. Gerhardt HJ & Otto HD : The intratemporal courseanomaly. Before any surgical procedure, of the facial nerve and its influence on thethe surgeon should have analyzed the development of the ossicular chain, Acta Otongol 91567-573,1981.benefits of the surgery for the patient over 14. GoodhillV." Complications ofthe surgical treatmentand above all accompanying risks of the of otosclerosis," Otolaryngologyed. by English,rev.contemplated procedure. It should be ed. Harper and Row, Philadelphia, 1986.stressed that the most common cause of 15. Fisch U: Prognostic value of elctrical tests in acutefacial paralysis, Am J Otol vol. 5 no. 6: 494-501,facial nerve injury in congenital ear Oct,1984.malformation is the failure to recognize the 16. Hough JVD : Ossicular malformations and theirfacial nerve. If a dehiscent facial nerve is correction.Proceedingsof the ShambaughFifthsuspected, intra-operative monitoring of international Workshop on Middle Ear Microsurgeryevoked spontaneous activity of the facial and Fluctuant Hearing loss. edited by Shabaughand Shea, The Strode Publishers, Inc. U.S.A., 1976muscles should be done. Adequate 17. Miehlke A : Etiology and varieties of congenitalmonitoring will prevent unnoticed traumatic malformations involving the ear. Proceedings of thesection of the nerve. An inexperienced ShambaughFifth InternationalWorkshoponMiddlesurgeon who finds a large dehiscence of the Ear Microsurgeryand FluctuantHearing Loss,edited by Shambaugh and Shea, The Strodefacial nerve should stop the procedure and Publishers, Inc. U.S.A., 1976.send the patient to a more experienced 18. Schucnecht.Stapedectomy, Little Brownand Co.,center having monitoring equipment for the 1971.facial nerve. 19. Lacour MA : latrogenic facial paralysis. Proceedingsof the Sixth International Symposium on the FacialNerve. Oct 2-5, 1988, Rio de Janeiro, Brazil. ed. byD. Castro, Kugler & Ghedini, 1978.20. Schuring AG : latrogenic facial nerve injury, Am JOtol vol. 9 no. 5: 432-433, Sept., 1988.21. Lathrop FD. " Facial paralysis of truamatic origin :BIBLIOGRAPHY prevention and treatment, " Otolaryngology " ed. byEnglish, rev. ed. Harper & Row, Philadelphia, 1986.1. Jarsdoerfer RA : Embryology of the facial nerve, AMJ Otol vol. 9 no. 5:423-426 Sept 1988.2. Mayer TG & Crabtee JA : The facial nerve coursinginferior to the oval window, Arch Otolaryngol vol.102; 744-746, Dec 1976.3. Jarsdoerfer RA: The facial nerve in congenitalmiddle ear malformations, Laryngoscope vol. XCLno.8: 1217-1224, Aug 19814. Jarsdoerfer RA: Congenital malformations of themiddle ear, analysis of 94 operations, Ann Otol 89:346-352,198O.5. Beales P. Otosclerosis. Bristol John Wright & Sons,Ltd 1981, pp 109 & 135.6. Herrman & Dlggelman : latrogenic intratemporallesions of the facial nerve. Proceedings of the SixthInternational Symposium of the Facial Nerve, Oct 2=5, 1988, Rio de Janeiro, Brazil. edited by D. Castro,Kugler & Ghedini Publications: 267-271.7. Althaus & House: Delayed post- stapedectomy facialparalysis: a report of five cases, Laryngoscopre 83:1234-1240, 1973.8. Ma M. The Facial Nerve ( Chap. 20). Thieme, Inc.,New York, 1986.

TableIV,FREQUENCY OF FACIALNERVE DEHISCENCE DISCUSSION AND COMMENTS'"/_UTHOR '/_ofDehiscent vii AREANervo Persistent immediate facialShaml_lugh 50% (opinionon_y;'n'o abovethe oval_1976)statip.tics given } window paralysis is rare after stapes surgery. It mayPenman(1976)*nodat, nodat= be due to surgical trauma, a dehiscent facialHough 40% level ofoval nerve, or an occasional inadvertent bone(1976) windowWlet, Davies& "common" ' '" tympanicaraa chip penetration. Immed!ate facial paralysisShamba=gh calls for an immediate(1982,a_t_r(1982) _ _,e_ofova_ electroneu ronography (EnoG). Surgical300/535bones temporal window exploration is indicated if denervation of the'(.... frequent in otosclaroaisears than in chronic draining ears) face reaches more than 90% within (6) daysof onset of palsy.The most frequent sites ofdehiscence in the bony wall of the facial There is no doubt that everycanal are in the area of the oval window otologic surgeon should suspect a possibleniche in two-thirds (2\3) of cases. More middle ear anomaly in a patient withmarked anterior displacements of the nerve congenital aural malformation. It has beenare well known from many observations, observed that as the degree ofThe oval window may be partially or totally malformation worsens, the greater theoverlaid by the nerve. This results in various incidence of middle ear anomalies. It is alsomalformations of the stapes even to the important to establish the onset of hearingextent of complete aplasia. The impairment, family history of deafness,developmental disturbance may also affect infectous disease in childhood, and otherthe incus. An anterior displacement of the pertinent data to consider congenitalnerve may prevent the formation of one or conductive hearing impairment. The historyboth crura. Interposition of the nerve of diminished hearing since childhoodbetween the labyrinth and the branchial part without any history of aural discharge orof the stapes blastema prevent the other infections which may lead to unilateralformation of the footplate and oval window, hearing loss points to a congenital condition.The stapes rudiment may rest as a flat bow The microtia of the patient is another clueupon the nerve. (Pou 1963 and Hoogland which can lead the surgeon to suspect an1977). aberrant course of the facial nerve andmiddle ear ossicles anomaly. Many reportshave confirmed that the degree of microtiaindicates the degree of congenitalmalformation of the facial nerve and middleHoogh, in a twenty-year review of ear ossicles. 4various ossicular malformations concludedthat all otologists should come to realize The facial nerve which wasthat even a severe "normal" middle ear is anteriorly displaced and completelyas unique as the human face and that even dehiscent in its tympanic portion isa severe congenital malformation abnormal and is related to the congenitalproducing a loss of function is indeed malformation of the middle ear ossicles"common" and reports a 40% occurrence of during its embryologic development. Aa dehiscent facial nerve and its oval window partial dehiscence in the area of the ovalencroachment in all ears. Rarely, however, window is considered a normal variantthe facial nerve may take an unpredictable because of its common occurrence.course as in the following instances: (1) itchanged its course entirely from above the latrogenic facial paralysis shouldoval window but inferior to it and across the not occur if the surgeon is aware of thepromontory; (2) congenital absence of the presence of a dehiscent facial nerve.oval window and the nerve completely Monitoring of the facial nerve function is ancovering the floor in the (2) cases; (3) a invaluable tool in avoiding this tragedycase of a unicrurate stapes resting on the which, according to some authors, maynerve trunkitself. 14 occur in spite of the most meticulousmicrodissection.

ang:ilorLqat:paiagirLg: : disciiarge issuing from the middle meatus..... i:si :_si.ia y su.gi}_'s{9e Of: :aida sna : ilasa :polyp at the _ighl, middle : : :: :i:ii_ino:Sir{,iSitiSi: :::T'he:cause of : meatus: t,hin_ i_on-pu_uient, i_on-:_]an_ i V:8::':gd:,: a le[gic, lflammalor_: oi ........... toul.smellmq:dlsc.harge. 7hc_ upright Waters ......ile i i _iii view :b0tll': tilaxillai_.............. caLises aide:: : :: sinuses}: : ::: : ::-- :: : :: : :: :: :6f7 v:e:ai: i i| :::: ::i)ie:se:ited: nt ::of:: n _u :Siehasbee:i:s:i-ffe!:]g::: i :...... :: : : : '": " : : : i_ dpri'gl]_:½'a_'s vii ,;' o £k esRust ....: T /]:aS:al:0t,)s_l:uf:.'._lo_, ro_::me:past:_u years: : : : : : :......... ..... .... ..... ........ ........ :.......... : ..... .... : endos, li.,lc,ally_gulded lntranasalel=V_ tii:ide_i' tooal :ane,sth:eSia ........:::: :::_ ......... yea G:: !i!:e_o adrnisSio n: af:]d :tW0: :: : Int{aLope_at'ively::: middlei:ie staIk b th e polyp at thecoming out..... " .... .... -, ...... r2al_l[ : fi'om a smatt::opel_i_9 il_the m:axitlai_: ,ostium.......... _ .... ...................... ....... was performed left. :: :: Regul:re.i ::: 'The potyp0id ::hi:asSat the il_lferii:i:i_:meatus .......: Was first thought:ti_ be an e:xtensi0 of that .... ......

:::i :: :: m:_i_::;osa:waspoiyp:o d and: severa :::: bacteriai::g !0wt i Ths s what happened 1:0.... nthe:max ,ary: :o"l"ot imooos ;: S 1us _iaVit:2coge_ed With ih(ke _ed::pus:w th:: ::: : mpa mucc ciliary: act_'' o. tiurr : :::::b:a_.iksh: :pate les ovi:,_"y t ::Wth ..... subseque i_: polyp ::t0::e_iai:_t:::it frol_: oStium: :aiid:: ntractability to Surgical: : : :have beer partly:caused by :i:!_imoVetti:e baii:qik:e itspre:sence:. .... : : :: : : :re-noved: and: extra:cted::out by: the body ......_g !iasal:: : itself: d d::: 1or he trl_e.. Fortunately ....:_uiUterit: dis..f_a_g_.: ::'so ..een:: s .............. : granu oma: fei!mation di:d not[ occur as a : :Ihe: max aty:ost UT_::w:a:s:::: ::: : react on to:th:e: Oonthiued :presenc.e: of the: : : :: ::: SOated::aiieas:::0f : Fie:ypo d: muc0sa were: :::: :: : : :: ., ..... ..... ' :::: : _0t:ed :: :: : : ::As de:from the_: usuai factors which :: ............................ : ::causesnusts:: ti_.nan factors and: technicat : : .....:: : er'rors: m:iJst:be::COnsidered. : This:case of an: : : : : :iatrogen :cal caused Chronic sinusitis : ::::::::::: ' : : ::::: :ted p#yscianS that: only :::::::: ::: :::::: :: : : :: :::: :: : scrupulOUs::a:tt:entiOnto:sui"gical:pl:ocedures: ::........... : ....... ......Endoscop¢ _mus our! e_y..... The: : : : :nge, : Technique: Mosby : ::: ....... :: : Y:ea_:t)oOk;:1991:: : ..... : ::: 2,: :: Staliey: L,.: et aL; ::: : ::Basisi: : of D:ise£se, : 3rd : : :3 Rubiil:Emmam_e :MD eta._%thoiogy: ::

develoopmentPost-operatively, a Denhard mouthwith re,at_veprognathismgag was installed to maintain the patency Cockayna's A_ ..... I Ow_n_sm Congenitaland to prevent synecchiae of fresh tissues, synd ......... ave ah...... increase inft_eth,dentalA dental obturator was fitted at the third........,rophyofalveolar process,post-operative day for less traumatic andoondy,arhypoplasiamaintenance of an oral cavity, e_=n_oo=_=,r Auto$omaJ Growth redardatian, MicrostomJa,• al dysl_t_a domlrLant flexion ¢ontraotura small mandibleI_

::::_:_::_:_:_::::_::_:::_:_:_:_::_:_::::_:::_:::_:_:_::_:_:_::_:_:_:_:::_::_::::_:_:::_:_::_:_:_::::: :_::_:_:_: :::::_::::_:::_::_:::_:: _:::_:: :_:_:_:_:::_:__ :i :,:i ¸: :(:/: :: i:i i :!_: Wide : li_:iiai_iha :; distance : P ' '" _: _ ._': e _t:a_kab_ i dOscop c _ ld : ::denta obtu_:aii_!to keepthe 1 Cm opening ci": ....:: _ ' ....... : ..... ":,"_, :L-L:4, bavitv from co_lapsin¢ Again_ : ....

proposed consanguinity of the patients of literature showed increased incidence ofseem to be likely, suggesting an autosomal malignancy in older children and adults. Allmode of inheritance, in all, hemangiopericytomas must beregarded as unpredictable neoplasms andLater histologic feature of the tumor as malignant, not in the usual 5-year survivalir_clude (1) sheets of spindly cells sense, but over the lifetime of the host.surrounding numerous capillaries, (2) These tumors are locally aggressive andmonotonous round to oval nuclei usually infiltrative and manifest a high recurrencelacking frank anaplasia, (3) indistinct rate, frequently persisting for years.cytoplasmic borders, and (4) on silver Barkwinkel and Diddams (1970) found astaining, each tumor cell is seen to be total recurrence rate, local and distant, ofsurrounded by a reticulin sheath outside of 52.2% in 224 cases (table 3).the capillary walls. A histologic gradingsystem was proposed by Tang and co- Table3.RecurrenceRatesof Hemangiopericytomaworkers (1988) classifying the tumor intoGrade i, Grade II, and Grade II (Table 2). Location Cases# Recurrence#Percentagemusculoskeletal& skin 103 50 50.5intra-abdominal& 39 16 41.0Table 2. Histologic Grading of Hemangiopericytoma retroperi_toneumLun_lmeclias-tlnum 22 10 45.3GRADING DESCRIPTION orbit, mouth,nasosinus21 12 57.1centralnervous 15 12 80I These are hypooellular lesions containing systemcells with small ovoid nuclei set in fairly Modifiedfrom Barkwinkeland Diddarns,Cancer, vol.25, 1970.abundant cytoplasm without prominentnucleoli,and with zero to I mitoses per 10high power fields (HPF) (HPF=X250). A Some variants of"deer-antler" vascularpatternis a strikingand hemangiopericytoma are observed incharacteristic feature, several cases. The congenitalII Thes_ are lesions that are more cellular, hemangiopericytoma is said to be a crossCont,_iningshowing pepperymoderatechromatin,sizedsmallovoidnucleoli,nuclei between hemangioma and hemangio-and from 2-4 mitosesperten HPF, The"deer- pericytoma. Campagno and Hyams (1976)antler"vascularpatternis usuallyprominent, designated a variant calledIII .... These lesions are characterized 'l_y more hemangiopedcytoma-like tumor. This lesionnumerous cells wilh small amountsof is believed to be within the spectrum of thecytoplasmatypical chromatinand enlargedpattern,nucleiatypicalcontainingnucleoli,classic hemangiopericytoma, yet hasand mitosesgreater than 4 per 10 HPF, A sufficient characteristic features related to"deer-antler" vascular pattern is much less location, behavior and histologic pattern todiscernible than the lesions of other grades.Tang, Gold, Mira, Eckardt, Cancervol 62, 1988, warrant its recognition as a related yetdistinctive entity. This type of tumor isSince the early 1970's attempts usually found as an intranasal masshave been made to differentiate between producing variable degrees of obstructionbenign and malignant hemangiopedcytoma and recurrent epistaxis. This tumor demandsbut, up to the present, there is no clear cut a less aggressive management because ofdistinction. McMaster, Soule and Ivin (1975), its low recurrence potential as compared tobased on the Mayo clinic experience, the classichemangiopericytoma.agreed with Stout that tumors may bemalignant if it is larger and deep seated, if itexhibited few mitotic figures with moderate TREATMENT AND PROGNOSIScellular anaplasia, if with foci of necrosiswithin a given tumor. Enzinger and Smith The treatment of choice is wide(1976) based their criterion of malignancy on surgical excision but as a single mode of4 or more mitotic figures per 10 high power management it contributes to 20% to 50%field_ To date, this is the most important rate of local recurrence. Mini etal. (1977)predictive factor for malignant behavior, have discussed the merits of radiotherapyOther histologically unfavorable factors may and found a response rate of 90% withbe high cellularity with seemingly immature complete regression in 47% of 29 patientstumor cells. Also, patients with small well with local recurrences. Best response wascircumscribed tumors had a 92% 10-year obtained when tumor size was less than 5survival rate as compared to a 63% survival cm. in diameter and with doses above 35rate in patients with tumors greater than 8.5 Gy. Chemotherapy has been used by somecm. in diameter. Another factor attributing to authors as a single mode of treatment. Theits malignant nature is patient's age. Review chemotherapeutic drug combination usually

......... F_U_,_ _- : _'{..... the data gathe:ec twasconc_dedthat {')..] _" .......... _" gu _e.:'_,, ..... _ .... ': : "t: .......... : .... : involvement in both sexes was equal, (2)the..... patients: :if!aTi_ged from .... neonal:es ' tO:: ::::::::::::::: -- : octogei_a:riafls,: (:3) the tumor had arl: :::: aggressiv:e:::gr0wth pattern, (4)lt_ere was ahigh ncideu_ce 0.trecl rrence, and (5)50% of............ the tumOrS: With: distant metastasis was..... ] ....: ide_itifYi:ng :: of[ the" per t,,yle, ....... was ......-- : :described by the Swiss pathologist :: :::: ::::i:::[::_ :: :: Zimme:rmai!iri: h::i 923 who noted that this : :............ ....... ........: :::::: [::[:celiis_0t:c0rii._ected with arterial or venulecell ir_fim:aiel2: Sul"i'our_ding the capilla_:: Ceils the capillary that..... : :: d0nStituteSi::: : .ihe [:_fiagilosis " of-- .......... ,,_Jso p_..cul_a,to the[[:[ : Hemai_g epe:ri:eytoT_a: _ _- "' ........ tume_ is the t_ltra st_-uctu_

contains adriamycin (doxorubicin). The mosteffective treatment to control tumors as well 3. Aufdemorte, Hemangiopericytoma-likeas to decrease the incidence of metastasis tumor of the nasal cavity, Archives ofseems to be surgery with high dose Otolaryngology 1981 vol 107: 172-174.radiotherapy and chemotherapy. In 4. Pitluk et al., Hemangio-pericytoma, Theconclusion, it is incumbent upon the surgeon American Journal of Surgery 1979 volto make every effort to excise the neoplasm. 137: 413-416.This might include adjunctive radiation and 5. Stal et al., Hemangiomas,chemotherapy to shrink huge masses to Lymphangiomas and Vascularallow resectability. Careful assessment of malformations of the head ad neck, nonage,location of tumor and general condition squamous tumors of the head and neckof the patient is important in establishing a vol II, The otolaryngology clinics of northreliable prognostic profile. The pathologist america, Nov 1986assumes an important role in accurate 6. Chow, Non-squamous tumors of the oraldetermination of histologic grade, adequacy cavity, non-squamous tumors of theof resection and the presence or absence of head and neck vol I, The otolaryngologicunfavorable histologic elements. Survival of Clinics of north America, Aug. 1986.patients with hemangiopericytoma in 7. Batsakis, Vasoforrnative tumors,selected sites (e.g. maxillary antrum) may Tumors of the head and neck 2nd ed,be improved by routine adjuvant therapy, 307-310.Similar tumors in other sites (e.g. skin) must 8_ Paparella, Tumors of the Nose andbe evaluated on an individual basis. Finally, Paranasal Sinuses, Otolarygology volit must be emphasized that the total number III, 3rd ed, 1945of these lesions reported to date is small. 9. Cummings, Neoplasms, Otolaryngology-Therefore, close, long term observation of Head and Neck Surgery vol I, 2nd ed,present and future cases is necessary. 759-760.10_ Lee, Tumors of the Jaw,EssentialOtolaryngology-Head and NeckBIBLIOGRAPHY Surgery, 5th ed, 56811_ Caparas et al., Basic Otolaryngology,1. Tang et al., Hemangio-pericytoma of 301.Bone, Cancer 1988 vol 62: 848-859. 12_ Lattes, Tumors of the Soft Tissues, 2nd2. Plukker et al., Malignant series, 194-198Hemangiopericytoma in three kindredmembers of one family, Cancer 1988 vol61 : 841-4.

HIGH DOSE RATE BRACHYTHERAPY AS AMANAGEMENT OPTION FOR STAGE I SQUAMOUSCELL CARCINOMA OF THE GLOTTIS:A PRELIMINARY STUDY*RAYMOND VINCENT P. JURILLA, M.D.**BENJAMIN SA. CAMPOMANES, JR., M.D.***GIL M. VICENTE, M.D.***EDUARDO TAN, M.D.****ABSTRACTThis is a retrospectivecase series involvingfive patientswith stage I glotticsquamouscell carcinoma wherein high dose rate brachytherapywas used as the primary mode ofmanagement.To date,these patientshave shownresolutionof the tumor withoutany damage tothe laryngealmucosa, vocal problemsor recurrencesafter 18 weeks of follow-up.Two patientsstillundergoingbrachytherapyshowedmarked decreasein tumorsize_Despite the limitedexperience, HDR brachytherapycan provide oncologic controlandpreservevocalfunctionwithless morbiditythan either surgery or external radiation therapy. Thismakes it an excellentmanagementoptionfor patientswith Stage I squamouscell carcinoma ofthe glottis.Key words: Brachytherapy, squamous cell carcinoma, giottic, stage IINTRODUCTIONThe larynx is the most common site irradiation of the surrounding structures.of malignancy in the upper aerodigestive High dose rate (HDR) brachytherapy is atract. Squamous cell carcinoma accounts for form of brachytherapy where the radiation90-95% of these malignant lesions. Most delivered exceeds 200cGy/min.laryngeal tumors are located in the glotticcompartment which fortunately has the bestIt is the main objective of this paperprognosis. One reason for this is early to describe the experience gained by thisdetection because these lesions cause institution in the use of HDR brachytherapychronic hoarseness which prompts early as a valid and practical treatment option inconsultation. In the management of early the management of Stage I glotticglottic carcinoma, it is generally accepted squamous cell carcinoma. In addition, thethat the first line is radiation therapy with specific objectives of this paper are:surgery (cordectomy, hemilaryngectomy)reserved for irradiation failures.1. To demonstrate that HDR brachytherapycan cause resolution of Stage I glotticBrachytherapy is a form of carcinomaradiotherapy where the radiation can bedirected only to where it is needed. It is able 2. To show that HDR brachytherapy canto deliver a high dose of radiation to a wellcircumscribedarea without excessiveprovide more patient satisfaction in terms of:"1_¢Place, PSOHNS Descriptive Research ContestOctober 27, 1995,Holiday Inn Hotel, Manila**Resident, Department of Otorhinolaryngology, St. Luke's Medical Center***Consultant, Department of Otorhinolaryngology, St. Luke's Medical Center.... Chief, Section of Brachytherapy, St, Luke's MedicalCenter

iii i i ....:: :: TheproCedure._,,,,atilete_,-__' '_"::was withdrawn after lhe:_ five done 0,7 a weekly basis: : :: depending on the size of Iumc_- and: : :: : response to thelapy.. Details of t_e HDRbrachytherapy sessions are shown in Tabtei"eit'ld_e:aftei' Ioa_i.iitaii .,: " : Brachvthe_'a_:,V maChir_-_ [ : minutes done on an out-patient basis,...... Table 2. @_i_ctWtiiel'a_V Records of Patie_:ts] :'5C_.- h:.3,.G,ymlI 0t:rrlradlU!:,;::}: :......... i:: :.... : ..... RESUL"rS..... :i : ?'o date, tile l_f-ee patients who:::::::] : :.... : :: have completed their therapy show total:::: ] : : ]: :::: resokltion of their tumors, h_ all patients........ ::: ::::[ there was rto da'_nage--"to the mucosa=: : .... : followinc t brachytherapy, tn this series, there]:......... were no complications related to the.... ::] treatment. Vocal function went 9ack to: ] ::::::]:: : : ]: : _;.._.:!.i. : ::::: normat ,cii" eve__ improved. Att patients.... : : : ] ] expressed:satisfaction with the results ofthe: : ] : : : :] ] /":i_Llre;3C:::P_l(th'_qS:p_!,Cia}r]qidHTR Bl"_lct%,ilietapv ] trealment and the _esotut[on of the. massi _:U:x:llicatof it', t:.i_c_,:\,,iasu_per_sior'., I_wyr,qosc.ocw;"i3A: WasvideoctoselYequipment,doc(,uTtentedDaringUSinghoarseness was noted resolve within foiiow-up.Sl:andarcl one: : [ : [ ] :F':br: aisotherteCtlnique: [ : molt_ ?"cm -riTeIast treatment day. Tl_ere=:::: }[:::::::::::[: : ::@_lpk:_.ved, based is_"_ pt"S!ViOLIS :: [ was aide n!:._report of radiation necios;s or[ :: : : ,of HDR br:aclt'ythel::ap,_l on mut.,osit;s.: t!:ot':the patients whose sessions................ :::] : :i'.[inesi:tlesia

with HDR brachytherapy alone. Details area. voice quality shown in Table I.b. exclusion of normal tissue intreatment areac. cosmetic acceptability Table 1. Clinical Profile of Patientsd. convenience with regards ...... ,_,_................... _o,,o_o_yto treatment schedule .... '......... ,nclude_nt.rlLlr o,,,_...........................nnmrnhzSHr.(T_hIdlt(_er_l_edsquem_u_r_'cpnomaA C 65/M _lrlor 1/3 c_flift vocll cord (Tla] ModeretelyThis study is significant because an ..............._.Qu_,_,o cerrextensive foreign literature review did not .............................. {T,,_ _o,_'°_,% ..........show any previous study which documented;;;_;_,_.,the use of HDR brachytherapy for early ............. '........... _°*'"'" .................. ,_oo=o,,_ _.,,c._rc,,_o,,,,)glottic carcinoma. Furthermore, this is ................. ............... ,T,,, .................... "probably the first locally-based study of ..............specific application of HDR brachytherapy inthe region of the head and neck. It suggests All patients were followed upan alternative mode of management which monthly after the last treatment session.promises none of the morbidity of external Follow-ups'were made regularly and werebeam radiotherapy, the present accepted closely monitored and documented. At eachmanagement for Stage I glottic carcinoma, visit, direct visualization of the larynx, eitherAlso, there is added significance for the ENT by flexible rhinolaryngoscopy or using a rigidsurgeon since this paper suggests a 30 degrees endoscope, was performed.technique of radiotherapy which maintains Quarterly scoping will be done on follow-upan active participation in the delivery of for the next two years.treatment to the patient.IRRADIATION TECHNIQUE:MATERIAL/METHODS For four patients, the followingprocedure was done. Under generalCLINICAL DATA.- endotracheal or intravenous anesthesia, theENT surgeon did suspension laryngoscopyFrom April 1994 to September 1995, to expose the glottis, then placed the speciala total of five patients with Stage I rigid HDR brachytherapy applicator insquamous cell carcinoma of the glottic contact with the identified tumor (See Fig.larynx were treated with HDR 3C). The applicators were held in place bybrachytherapy-therapy in this institution. All fixing them externally to the suspension.diagnosis were based on histopathological Anteroposterior (AP) and lateral x-rays ofreports. There was no clinical evidence of the neck were taken for verification of themetastasis at the time of diagnosis. Staging position of the applicator and for treatmentwas done according to the system planning. The radiotherapist then calculatedrecommended by the American Joint the dose to be administered based on theCommittee for Cancer Staging. Stage I clinical assessment of the tumor size (seeglottic refers to tumors limited to one (Tla) Fig 3B)_ (Being a new application of HDRor both (Tlb) vocal cords with normal brachytherapy, the radiation dosesmobility, without neck node (NO) or distant employed here were based on a largemetastasis (M0). There were three male and volume of international studies done ontwo female patients. Four of the patients other organs, specifically the cervix). In thewere in the sixth decade, one was 24 years brachytherapy room, the applicator was thenold. Four patients were newly diagnosed attached to the "high dose-rate remote aftercase of glottic squamous cell carcinoma, all loading brachytherapy machine", whichof whom were managed with HDR delivered the prescribed Iridium-192brachytherapy alone. One patient was a radiation (See Fig. 3A). After the treatment,case of glottic squamous cell carcinoma the applicators and suspensionpreviously managed with external radiation laryngoscope were withdrawn and standardtherapy with recurrent tumordescription of a Stage I lesionfitting there-irradiatedpost-operative care was administered.csrl

.... .... i:: ::: :::: : :D SCUSSiON: : ..... ",,me iarw × the:most common s te: : :: : ::__::: : : : Of malignancy :in the upper aetodigestive: : : ::::: :[__!_ :: : tract. The tumor histopathoh:,gy is: __: : .... ::: squar'tots cell:c.arch_oma in over 90% of: : : .... cases., bor the purpose of cta.ssrf,cahon[: :: and :c0nsideration of appropriate::: : : !:_c_-e P_m_:i_:'_'i ,,.v.:.

external skin necrosis and unsightly burnSince 1975, many authors have marks on areas outside the intended target.been recommending the use of carbon This cosmetic disadvantage is most markeddioxide laser 11 as an alternative surgical in the head and neck region_"knife". Cure and recurrence rates arecomparable to conventional surgery and Even before any sign of skinradiation therapy though not any better 16 necrosis begins, however, the patient's oralComplications in laser surgery, though, are and pharyngeal mucosa membrane willrare. already become erythematous, proceedingto a stage where a fibrinous exudateIn most countries, irradiation is the appears. This is called radiation mucositis.initial treatment prescribed for early There is intense pain especially associatedmalignant tumors in the glottis, with surgery with swallowing, making the patient more(hemilaryngectomy or cordectomy) reserved miserable with consequent decline infor salvage of irradiation failures. _ This nutritional status. External radiation affectsprotocol was developed because it was the mucous membrane directly by reductionnoted that for small glottic carcinomas, 90% of mitosis of the normal cells. Indirectly, itof cases are cured by radiotherapy alone, causes endarteritis leading to ischemia ofwith salvage surgery curing another 4-8%. _6 the mucosal tissue.;While some studies seem to indicate thatmost patients who undergo external Assessment of the irradiated larynxradiation will eventually regain normal voice proves to be difficult as a result of thefunction, abnormal voice characteristics swelling and edema from external radiationoften persist. Phonation following external therapy. Thus, an occult carcinomaradiation therapy is generally considered to (recurrent disease or second primary tumor)be less impaired following conservative may progress beyond what can be salvagedsurgical treatment. 17The study by Chert et surgically. _s_7 In addition to this, theal. (1993) showed a 77 % voice prolonged edema may likewise causepreservation for post-radiotherapy cases narrowing with vadous degrees ofcompared to 34% (improved to 60% after respiratory obstruction. The protracted1988 with more conservative technique) for edematous condition may lead to repeatedpost-surgical patients. 12 This would indicate biopsies, with subsequent perichondritis andthat radiation therapy is the treatment of stenosis. 2choice in early vocal cord carcinoma, as faras preserving vocal function is concerned. Also, the risk for radiation-inducedtumors must be kept in mind. Although theThe external beam irradiation frequency of such is low (0.1-0.5% in adultstechnique for T1 lesions usually employs a and 1-5% in children, developing 5-25 yearsfield that includes the larynx from the hyoid post irradiation), the importance of even abone to the cricoid cartilage using anterior few is great because such tumors areoblique wedged fields. (Good local control is usually fatal, and appear long after theachieved with 200 cGy per fraction for a total primary tumor was eradicated and thedose of 6500-6600 cGy. _5 patient perceives himself to be recoveredfrom cancer. The stress of the lateAlthough external radiation therapy, appearance of an induced tumor, not only tobe it the old Cobalt units or the newer linear the patient but also to the relatives and theaccelerator, may seem ideal for treating involved medical team, is unusually severe.early glottic carcinoma, it also has its own There,will almost certainly be a decreasingsignificant morbidities. Much of these arise tolerance of such untoward outcomes whenfrom damage to uninvolved normal tissue in the induced malignancy appear in non-targetthe treatment volume. The types of tissue and there were other technical meansradiation damage may include tissue (even if costly) available_ So what was oncenecrosis, fibrosis, strictures, atrophy, poor an acceptable morbidity in the past may nothealing of a surgical wound and radiation be acceptable now because of availableinduced neoplasia. 25 Because of the technology. 24exposure of a large volume of tissue toirradiation, the patient is prone to develop

Furthermore, another disadvantage oropharynx, including base of tongue, lymphof external beam therapy is the treatment node metastasis and the nasopharynx.3'19course which usually takes six and a halfweeks on a once-daily basis. This scheduleIn irradiation therapy, there are twomakes it inconvenient for people who desire classes of failure: local control not achievedto continue their daily routine despite their and radiation induced morbidity.24 Withillness. There is the added inconvenience regard to the former, as far as early stageand expense of going to the hospital glottic carcinoma is concerned, HDReveryday, brachytherapy has excellent resultscomparable to or even better than externalThus, factors other than cure rates radiation therapy. But it is in the area ofand functional (voice) results must be radiation-induced morbidity where theseconsidered and may also influence the radiological modalities markedly differ. Thechoice of therapy. Besides, no truly morbidities and disadvantages of externalinformed patient would agree to have his/her radiation discussed earlier are notnormal tissues (non-target) irradiated when experienced with HDR brachytherapy.feasible means were available to excludethem from the treatment volume and couldIn addition, there is improved dosealso be assured of coverage of the target in distribution. In radiation therapy, the goal ofthree dimension treatment sessions,treatment planning is to achieve the closestfeasible approach of the treatment volume toTherefore, those patients who have the target volume. Brachytherapy is able tothe financial resources to try an alternative deliver a high dose of radiation to a wellmodalityand/or who do not have the time to circumscribed area without irradiation ofgo to the hospital everyday as an outpatient surrounding structures. Thus, in(as in external radiation therapy) or to be brachytherapy of the glottis, the laryngealadmitted (as in surgical treatment) must be apparatus, hypopharynx, neck muscles, andprovided with another option. Such option skin are spared from complications such asshould satisfy the desire of the attending persistent edema, necrosis, and poorphysician to circumvent the complications function. Plus, the risk of radiation-inducedassociated with external radiation therapy neoplasia is greatly minimized. There isdiscussed above. In this institution, to meet likewise an increase in the differentialthese valid demands, HDR brachytherapy response between tumor and normalas an alternative means of managing early tissue.24 The clinical benefits will be due toglotticcarcinoma was used. the irradiation of almost zero volume ofnormal tissue/ structures. The tumor andBrachytherapy is a form of interstitial the tumor alone receives the full impact ofradiotherapy used to deliver radical high the radiation.treatment to small target volumes. Itdeveloped from the parallel pioneering work An advantage of HDRof radiotherapists from France and England brachytherapy specifically is that it has ain the 1930s. High dose rate after loading short irradiation time which reduces the risktechniques have been in clinical use for over of embolism. Also, because of the shorttwenty years now.3 In contrast to external treatment time, the patient will not feel sobeam radiation, brachytherapy is performed isolated for a long time. In addition, theby placing encapsulated radionuclide exact position of the applicator can besources close to or within the tumor (the controlled during the therapy and can beprefix "brachy" is the Greek word for "short", reproduced throughout several dosereferring to this short distance between the functions. Thus, the higher dose-rate resultsradiation source and the tumor). Its main in a higher biological effectivity.3advantage is the ability to deliver a highdose of radiation to a well-circumscribed This paper is a preliminary report onarea without excessive irradiation of the the success of HDR brachytherapy in thissurrounding structures. At present, it has institution in treating early glottic carcinoma.been documented in the following head and In comparison to external radiation therapy,neck applications: lip and buccal mucosa, HDR brachytherapy has very much lessfloor of the mouth and mobile tongue, morbidity. Although Wang (1993) has

already shownthat the radiationtolerance of 4. Unsightly cutaneous burn marks inlaryngeal structures is high and has, in fact,the head and neck area are avoided.proposed an external beam technique for re-Likewise avoided is the Occurrence ofirradiation25, effectiveness of HDR radiation mucositis.brachytherapy for salvaging irradiation 5. For the patient, there is lessfailures have been demonstrated,interruption of normal daily routine.6. For the ENT surgeon, there isAt this point, the significant role thecontinued active participation in theENT surgeon plays in the delivery of therapyactual management and follow-up ofto the patient is emphasized. The ENT the patient.surgeon performs direct or flexiblelaryngoscopy three to five times a month forBased on the favorable experienceeach patient and puts the brachytherapy documented in the first five patients, it canapplicators in place. Therefore, this therefore be concluded that brachytherapyprocedure espouses a multidisciplinary can provide cure and preserve vocalapproach. It is a team effort--the core of function with less morbidity and morewhich consists of the ENT surgeon, the convenience that either conservativeradiotherapist and the anesthesiologist (if surgical treatment and external radiationgeneral anesthesia is employed), therapy for early stage glottic squamous cellFurthermore, the patient remains the carcinoma. This was achieved withoutresponsibility of the ENT surgeon during the diminishing the role of the ENT surgeon infollow-up stage and assesses the results of the active management of the patient.the therapy.With increasing awareness and RECOMMENDATIONSeducation of cancer patients as well asphysiciansas to the treatmentoptionsopen,Continuedfollow-upof the first fivethere will ultimatelybe less acceptance of patients is recommended for a long-termmorbidity due to damage of non-target assessment of brachytherapy effects_tissue which need not have been included in Because of the encouraging results derived,the treatment volume. This means that what continued application and more completeis or is not acceptable financially needs to documentation of this therapy forbe regularly reevaluated with the appropriate new patients is herebydevelopment/availability of technology that recommended. This paper will thus bewill do the least damage to normal tissue,extended to become a prospective cohortstudy. A study comparing the advantages/disadvantages of brachytherapy vis-a-visCONCLUSION external radiation on early stage glotticcarcinoma can likewise be undertaken.In summary, using HDR Another possible adjunctive study of interestbrachytherapy as a treatment option for would be a cost-effectivity or cost-efficiencypatients diagnosed with early stage glottic study concerning brachytherapy, perhapscarcinoma showed the following pertinent also in contrast with external radiation.advantageous features:1. All patients in this study have BIBLIOGRAPHYdemonstrated resolution (or markeddiminutionfor ongoingcases) of their 1. American Joint Committee on Cancer.tumormasses. There is yet no reportManual for Staging of Cancer 3rd ed.of recurrences for as long as 18 Philadelphia:J.B.LippincottCo.,1986.months afterbrachytherapy. 2. Bailey, Byron J. Head and Neck2. There is good preservation of vocal Surgery-Otolaryngology. Philadelphia:function. JB Lippincott Co., 1993.3. There is more efficient dose 3. Bartelink, H, et al. Brachytherapy 2.distribution resulting in increased Leersum, The Netherlands: Nucletrondifferential response between tumors Inter-national B.V., 1989.and normal tissue.

scan or MRI definitely would be more Radiologically, both present with bone andadvantageous, cartilaginous destruction but the location ofthe lesion of chondrosarcoma and chordomaThe occurrence of ptosis has given is mainly nonsphenoidal which is oppositethe patient more cause for alarm. But the that of the patient. Therefore, sphenoidEENT specialist has considered it to be sinus mucocoele or sphenoid carcinomaprimarily an orbital problem and an MRI of were the more important considerations.the orbit was initially requested, Acceding toa request from a relative doctor led to the Sphenoid sinus mucoceole ispatient undergoing MRI of the brain instead, caused by obstruction of the secretory ductMRI showed an enhancing mass in the or sinus ostium. The symptoms and signs ofcentral skull base. Consider newgrowth as in sphenoid mucoceole and sphenoidalchondrosarcoma, chordoma and carcinoma are directly related to sinusinflammatory process of the sphenoid sinus, anatomy and its contiguous structures.The lastoOtolaryngologist who saw the Headache is still the most commonly notedpatient considers the CT scan highly symptom; other symptom and signs presentsuperior than the MRI with respect to sinus in the patient are ptosis, epistaxis and facialpathology. The MRI is good for soft tissues numbness.-lesions while the CT scan shows the statusof the bony architecture which is important in The difference between the two is inthe evaluation of the sinus problem. The CT the radiologic picture. In mucoceole, thescan showed a soft tissue mass in the bony wall is pushed to the periphery. In thissphenoid sinus eroding its wall and patient, the lesion has gone beyond theextending to involve the cavernous sinus, confines of the bony wall to affect adjacentCT scan reading was sphenoid sinus mass, structures_ Thus, the prime considerationCarcinoma? The involvement of cavernous was sphenoid carcinoma.sinus could explain the presence of all theeye symptoms. The biopsy has been through theWigand approach to the sphenoid sinus.Based on the central skull base This is a safe and simple way to reach thelesion, shown in MRI and CT scan the area. Through this, a biopsy could easily befollowing were considered: done with minimal risk. Biopsy revealedsquamous cell carcinoma, moderately1.) Chordoma differentiated, sphenoid.2.) Chondrosarcoma3.) Sphenoid sinus mucocele $quamous cell carcinoma of4.) Sphenoid Carcinoma sphenoid is rare, accounting from 0.4 to 2 %of all paranasal malignancies. With regard toChordoma originates from the treatment, exhaustive review revealednotochordal rest whereas chondrosarcoma scanty literature. In a retrospective study byoriginates from the embryonal cartilage that J.D. Spiro in 1989, out of 105 patients withescape resorption during endochondral squamous cell CA of the paranasal sinuses,ossification. Despite their unique cellular one had surgery and remained alive andorigins, chordomas and chondrosarcomas well 5 years postoperatively but the otherthat originate at the central base of the skull patient was lost to follow-up after theshare many symptoms and signs, diagnosis. Other reported cases underwentradiotherapy but results of the treatmentIn this case, the patient presented were not mentioned.with severe headache, a common initialsymptom of chondrosarcoma and Surgery in this area is quite difficultchordoma. In the later course of the disease, because of its deep location and proximity tothe patient had ptosis and facial numbness the cranial nerves and other importantdue to occulomotor and trigeminal nerve structures. The surgery that could be doneinvolvement which were all unresponsive to in this patient is just debulking since a widemedication, excision of this tumor, having affected thecavernous sinus, is practically impossible.Epistaxis which was the initial The benefit of debulking with radiotherapypresentation of the patient is also seen in vs radiotherapy alone in advancedchondrosarcoma and chordoma, sphenoidal carcinoma with respect to the

survival rate is uncertain up to this timeBIBLIOGRAPHYbecauseof limitedexperience.The possiblemorbidityof surgery is quite high especially 1. N.J. Volpe (1993) Neuro-ophthalmologicsince the bony wall has been eroded and findings in Chordoma andthe dura involved, Comparingthe surgeryChondrosarcomaof the SkullBase. Amwith the uncertain results, radiotherapy Journalof Ophthalmology,115:97-104.would be a logical modality of choice. 2. J.A. Stankiewicz(1989) SphenoidsinusChemotherapyhas been givenin additiontothe radiotherapy on the ground that amucocoele, Arch. Otolaryngology,115:735-740.combination of modalities affords better 3. J.H. Dempster (1988) Squamousprognosisin advancedmalignancies.A wide carcinoma of sphenoid sinus inexcision of the tumor is practically associationwithinverted papillomatosis.impossible.Journal of Laryngology and Otology,102:938-940.Presently,the patientis undergoing 4. J.W. Harbison (1984) Neuroradiotherapyand chemotherapy and Ophthalmologyof sinuscarcinomabrainimprovementhas been noted. Ptosis and 107: 855-870.the limitationof the ocular movement has 5. J,S. Spiro (1989) Squamous carcinomaimproved. A repeat CT scan after the of the nasal cavityand paranasalsinus,managementis warranted. Am. Journalof Surgery, 158: 328-332.CONCLUSIONPresented was a case of a 58 yearold, male who developed a sphenoidalcarcinoma, having a 2 year history of on andoff epistaxis and a two month duration ofexcruciating headache. A high index ofsuspicion could have enabled earlydiagnosis. And as is always stated, earlydiagnosis results in better prognosis. Thatcould have been possible in this patient.Physicians, therefore, should be on guardfor all seemingly unharmful symptoms likeepistaxis and headache since these couldgive the patient the deadliest blow.

FACIAL PROFILE ANALYSIS: AN AVERAGE FILIPINOANTHROPOMETRIC MEASUREMENT*PHILIP DIONISIO M. ROA, M.D.**DEO MAGNO S. ANDAL, M.D.**EDGARDO C. RODRIGUEZ, JR. M.D.***ABSTRACTFacial measurementsof 100 male and 100 female Filipinomedicalstudentsand medicalstaffmembers(20-30 years old)weretakento providebasisin reconstructingan average Filipinofacial profile.Several factorswere consideredin the analysis,includingage, gender, and culturaldifferences.Basedon the computedaveragefor eachmeasurement,noticeabledifferenceswereseen inthe foreheadwhereinmales presentsa wider foreheadthan females. In the overall facialcontour,males have a relativelysquareface comparedto the roundedshape in females. Maleshave longer noses(4.14 cms) than females (3.96 cms). Consideringboth sexes, no significantdifferenceswas notedin the measurementof the nasolabialangle and nasal tip projectionusingthe Good method. Measuringthe Legan facial convexityangle, the males exhibited a moreconvex profilethan the females. In the process of creating an average Filipinofacial profile,discrepancywas notedin the measurementofthe middleand lowerportionsof the face as basedon Caucasian standards. Combining all the measurements, the author were able to form anaverage Filipino profile using foreign aesthetic standard&Keywords: Filipino facial profile, facial profile analysisINTRODUCTIONincreasing number of Filipinos, both malesand females, who have expressed theirPerfection in beauty is what persons desire to undergo facial profile plasty tofrom all walks of life, in every part of the improve certain facial features and/or toworld, wish to achieve. Even in ancient correct defects which may be congenital intimes, man has been in constant quest to origin or a result of trauma.define and measure beauty, and to,eventually, create it flawlessly. The GreeksPresent demands in this field hasattempted to form the perfect beauty through led some authors to establish standard facialmathematical and geometric equations proportions and relationships which providewhich led to the formulation of the golden basis for the diagnosis and planning in facialproportion of the human body. This surgery. These data, however, were basedproportion has frequently been described in on Caucasian measurements, and cannotLeonardo da Vinci's paintings, the so called be completely applied to Filipinos. RacialLeonardo's square, differences make Filipino featuresfrom that of Caucasians.uniqueSince the beginning of the twentiethcentury, aesthetic and reconstructive So, though using the standardsurgery has evolved into an important measurements that yield pleasing results, ittherapeutic specialty. Once a socially is the 'ultimate goal of every plastic surgeoncondemned work of art and science, it has to create an aesthetically acceptable andnow gained wide acceptance worldwide. In balanced facial profile which does notthe Philippines, there has been an"Presented, PSOHNS Descriptive Research ContestOctober 20, 1995, Holiday Inn Hotel, Manila**Resident, Department of Otorhinolaryngology, PLM-Ospital ng Maynila**Consultant, Department of Otorhinolaryngology, PLM-Ospital ng Maynila

: _ ::c_:e:_e:c_s o:r,:r_m aa a "_sto...... V or _:_ta_, a........:,,,,,_, _,,,o,,_,,, _,_,,,, _,_,_,,:,,_,_,__,,_ .... ....

evaluation of the facial width, males present.................... ,..... ::.::_-::. a relatively square face compared to the&;"_ ."q ..:..:!]:.i:!:.i:::;:_f:_F:_::i::_- rounded shape of females.• ._r.. :,,'- ..k;_]?'_ii:::'[" ..,,,"t:",_i_' ::_::.",:,:-_.....':i. In the measurement of individualJ :,,,:-,b-: .... :........... :',':, :.:,:.;.,-,,.:.,., _. i.!]i. _ aesthetic units, the most noted difference isii; ",. ........i;_:,: ,,-,.-,.:_--,., .... seen in the analysis of overall nasal contour,.........;_: ; :::_i! .... ..., ,,_;,":; '.,-d::The male gender has a longer nose (4.14", ,............... ; ,,i' cms) as compared to the female (3.96 (:ms)M&I.E FEMAI.E :_ using the nasion-to-tip measurement. Thetip-lobule distance is longer in males (0.57)than in females (0.47). There is too muchFigure9 variability in then nasal tip projection usingthe Goode method and the usual nasolabialDISCUSSION angle differences written in textbooks,saying tha.t the female has more obtuseAs Plato once stated: "The qualities angle than the male, was not noted in thisof measure and proportion invariably study (shown in table 3). Analyzing theconstitute beauty and excellence", overall facial contour, it was observed in thisTherefore, in order to achieve excellence in study that males have a convex face withthe presence of beauty, a certain degree of mentocervical angle of 106°, than femalerelative proportion of the various parts of the (91.8°). This was also proven using thebody, and, in particular, the face must be Legan facial convexity angle (male = 10°,established, female = 5°). Analysis of the earsdemonstrated that females have longer earsin formingSeverala basisfactorsformustanalysisbe putofinfacialmind (5.9 cms.) than males (5.3 cms.), but maleshave a wider attachment of the pinna.components. One is age which usuallyconstitute one's desire to undergo aestheticThis may be a predominantlysurgery. The initial effects of aging becomeWestern civilization but not all individualsapparent when one reaches the age of 30 would request change to have Caucasianwhen there is loss of skin elasticity and features. Persons may desire reconstructiveincrease in laxity. That is why, in this study, surgery yet wish to retain certain ethnic andthe authors limited the subjects to those cultural characteristics that are important tobelonging to 20-30 years age group, which their self image. In view of this, the authorscould give an ideal facial analysis without try to compare Caucasians and Filipinothe unwanted effects of the aging process, profile in terms of balance of proportionality.Using measurements based on such age Individual measurements of each aestheticgroup, the surgeon could satisfy the units were not compared to Caucasianpatient's goal in undergoing cosmetic values per se, but instead, these foreignsurgery---to rejuvenate one's lost youth, aesthetic norms were used as a guide inAnother factor which is vital in facial determining proportionality in facialstructures without altering the basic Filipinoanalysis and has been highly considered infeatures. Despite the discrepancy notedthis particular work is gender. Eachbetween the middle and lower facemeasurement has been grouped and disproportion-portion for the Filipinos (bothrecorded separately according to sex. As males and females) as compared to thewhat foreign authors have observed in Caucasians, the rest of the parametersCaucasian subjects regarding this aspect, show there is balance among the facialgender difference was also evident among structures of the Filipino.Filipinos. Based on the computed averagefor each measurement, there were severaldifferences noted between the male andCONCLUSIONfemale measurements. First is in the facialproportions. Males were observed to haveThere is no precious algorithm thatwider forehead (5.37 cms.) than the femalescould describe an ideal facial beauty.(5.19 cms.) using the distance Tr-G. In theStandards of acceptability and beauty are

quite varied in different parts of the world, BIBLIOGRAPHYand each ethnic group may have its ownperception about it. In this study, however, it 1. Nachlas, N.E.; Papel, I_D.: Facial Plastichas been proven that though tastes, and Reconstructive Surgery, Mosbyfashions, and standards of beauty may Company, 1992.change from age to age, from one 2_ Bernstein, L: Aesthetics in Rhinoplasty,civilization to another, the classical concepts Otolaryngology Clin North Am 8:705,of harmony, balance, and proportion remain 1975.the basis in the creation of what one may 3_ Converse, J.M.: Reconstructive Plasticconsider an aesthetically acceptable facial Surgery. vol 1. Philadelphia andprofile. The authors of this study were able London, W.B. Saunders, 1977, 2ndto reconstruct the average Filipino profile edition.which is proportional based on the aesthetic 4. Rees, T.D.: Aesthetic Plastic Surgery.norms of foreign authors. This could be a big vol 1 & 2, Philadelphia and London,step towards an advancement in the pre- W.B Saunders, 1980.operative assessment of patients to 5_ Marsh, J.L.: Current Therapy in Plasticdetermine which facial features need and Reconstructive Surgery, Head andchange to produce harmony with the face as Neck. vol.1, Toronto and Philadelphia,a whole and yet preserve one's cultural 1989.identity. 6. Llanera, K.A.: Facial Measure-mentsAmong the Filipino Female in MakatiMedical Center, Makati Medical CenterRECOMMENDATION Proceedings. vol. I11,pp. 18-26, 1989.7_ Maviliv, M.E.: Use of Umbrella Graft forThough this study has established Nasal Tip Projection, Aesthetic Plastican average measurement of Filipinos, the Surgery. 1993 Spring; 17 (2): 163-6.sample size used was not representative of 8. Byrd, H_S.: Rhinoplasty: A Practicalthe total Philippine population and of every Guide for Surgical Planning, Plastictribalgroup in this country. The authors Reconstructtive Surgery. 1993 April; 91recommend that a study of larger scale be (4): 642-54.done using a bigger population size, with 9. Coombes, A.M; Moss, J.P.; Linnet A.D.;each region of the country well represented. Richards, R.; James, DR.: AAdvances in computer technology can be of Mathematical Method for theuse in this project. Utilizing computer soft- Comparison of Three-Dimen-sionalwares, measurements and editing of facial Changes in the Facial Surface, Eur-Jfeaturescould be done faster and with more Orthod_ 1991 April; 13 (2): 95-110.precision. The plastic surgeon could thenconstruct a 2-dimensional representation ofa possible surgical outcome.With computer technology combinedwith human ingenuity, there is no doubt thatthe search for a perfect beauty is not that farfrom existence.

HEMANGIOPERICYTOMAOF THE PARANASAL SINUS*J. GABRIEL C. DE BORJA, MD.**ABSTRACTA fast growing tumor of the left maxilla was initially treated as pyogenic granuloma basedon pyorrhea and an initial biopsy result. Further tests disclosed the case as ahemangiopericytoma. Tumors like this respond well to wide surgical resection but location of theneoplasm, more than histological features, is important to establishing guidelines to treatmentand prognostication.Key Words: Maxillary tumor, Hemangiopericytoma,RadiotherapyINTRODUCTIONHemangiopedcytoma is a very rare stuffiness, occasional left sided epistaxis;mesenchymal tumor first described in 1942. and a downward displacement of the leftAlong with angiosarcoma, it is a general hemipalate. Consultation was sought with anclass of the malignant vasoformative EENT specialist who did a punch biopsy ofneoplasms_ Before this and even at present, the mass intra-orally. Histologic report waspathologists have confused this type of granuloma pyogenicum (capillary typetumor with various neoplasms such as hemangioma). The patient was given coglomustumors, Kaposi's sarcomas, amoxiclav and oral steroids for 3 months.mesenchymal chondrosarcomas and fibroushistiocytomas.Two months before admission, therewas progressive dysphagia and trismusalong with the enlarging mass. One dayCASE HISTORY PTA, patient consulted our institution fornoisy breathing and cachexia.C.D., 15 y.o., F/S, Roman Catholic, Tracheostomy was done and the patientfrom Polomok South Cotabato was admitted was admitted.for the first time in this institution because ofa left facial mass. Pertinent physical examinationfindings included a bulge on the leftEleven months before admission, maxillary area extending to the left side ofthe patient had intermittent toothache from a the mandible, the skin over the massloose upper left first molar. The patient was showing telangiectasia and tautness. Thegiven oral antibiotics and analgesics by the mass was fixed, firm, non-tender andschool dentist. Two months later, a painless approximately 12 x 10 cm. in dimensionswelling of the gingiva surrounding the left (Fig. 1-3). On anterior rhinoscopy, a fleshy,molar was noted. The same dentist fungating, slightly friable mass was noted todisclosed that he had pyorrhea. Tooth obstruct the left nostril totally. Examinationextraction was done and the same of the oral cavity revealed a fungating mass,antibiotics and analgesics were prescribed pale colored, occupying the left hemipalate,at higher dosages. Four months before gingiva and buccal mucosa. The teeth onadmission, the gingival mass progressively this side of the maxilla were embedded inenlarged accompanied with a painless left the mass, loose and medially displaced. Themaxillary induration. Other notable trismus narrowed the mouth opening tocomplaints included gradual left sided nasal about 1.5 cm. inter-incisor distance but therePresented, PSO-Clinical Case Report ContestApril 7, 1995, Subic International Hotel, Olongapo City**Resident, Department of Otorhinolaryngology, Davao Medical Center

:: : : Peripheral: blood :s:mear::showed:a ....:_ ,,,: _ : .... .,,,t_e_mocyt_ctype o_ anemia : : : :.... : : : :: Of....... ..... : ....... ....... ..... ......... neoplasm corr_pi)sed of: : : ::Sun'ounde, d by::pfoliferatinq round :io spindle : : :ceils, Foc:a_:areas showed: sotid l_odutes o-fmany : mitotic figuresl ::Official :fep6r{ ::Was llernang ope:r cvtos_a : :::: : malignant: :: : ..... ::: : : : :] ]...... ......... : :: : ::!i:bi:ii:!dei"_: :'Y:_i_e e,fl:rlax ar_::a:it_k :_:d:Witii :ihe::mass:, :The: :::and assessment: of tumor: extent:, includh_g : :: ::abs:ei_ :ai_:d: Wag:::: :th_.:-_ tt the.'-' : Si'-.cture_< : : : ::...... condt o i of the .......:..... : keW The:: :patient tl_e:s_l_ic:e: referred the case tO the : : ::_tP dSpaded ::: ::: Radiology: "ad at on therapy pr or tO : : : :::::: pi_,iiii_!e_as::_o : a:li,id: tumor: The .... :: ::: ::: :COtu'seof ii:adiothera:p'¢waS:uneventf_it iii the : : : ::::_,:{ ses ;:,.1_' i :....... :: first three:: wee:k:s:: Marked reg_'ession ili:::: : : :We:re:noted: Due : : : : :: ::i0 i:adiatiOil: :Ihe:patient decided to : : :.................... .... ....... ........ : :::::: :::: :forego:the::seCo:rid:::h:alf o{:the co,_'se aid : ::: :: : later, Seen :atthe ioom severely :anemic_,and : : :: :ReLevaluation: : ,_howec::: :::::::[ pi:Og :i_f:::tumor with:fooa areas of : : [..... i_ilt, Lple, _:cervical: maSSes. The. : :[:: ::::::::::::::::::::::: chest x-ray was read : ::::: :[:::::::as ::nom:_a] and patient was re-,,enrolled for9>12)_ :

Brainstem Response (Table 5 and 5). A The tumor could be presumed to havevariety of studies demonstrated a better than increased in size (2.5 - 3.5 cm) to reach the90% hit rate for acoustic tumors (see Table cisternal stage. The average growth of7). The ABR tracings for this patient these tumors are currently thought to beshowed presence of wave 1 is located in the 0.25 - 0.30 cm per year. There is a damagedistal (cochlear end) of the eighth cranial to the vestibular nerve and beginningnerve while the tumor is located more compression of the brainstem or cerebellummedial to this site, i.e. near the proximal leading to the cerebellar dysfunction evident(brain stem end) of the eighth nerve. A in this case. During the later part of thisprolongation of wave 5 due to stage, a (-) bilateral corneal reflex, as seendesynchronization may also be apparent in this case, points to involvement of thewhile a delay in all of the wave forms may trigeminal nerve, the first nerve to bebe evident due to compression of the affected once the tumor is outside theenlarging tumor. Another mechanism internal auditory canal. Finally, worsening ofinvolved in the generation of an abnormal the previous symptoms, signs of increasedABR is interruption of the blood flow through intracranial pressure due to hydrocephalusthe internal auditory canal which results in and lower cranial nerve palsies such asischemia of the nerve peripheral to the dySarthria and dysphagia points to the thirdtumor (retrogade degeneration) and also to stage of the tumor growth (>3.5 cm), thethe cochlea_ (See Table 2 for the expected brainstem compressive stage_ Theoutcome of audiometrJc tests in cochlear dysphagia may due to compression of lowerversus retrocochlear disorders). The cranial nerves or due to the thyroidsummary of these battery of audiometric pathology. The bilaterality of symptomstests done is detailedin Table 4. Vestibular somehow provided a dilemma in theassessment was made via diagnosis. A concrete diagnosis was onlyelectronystagmography. According to a given during this late stage of tumor growth.study in 1989 conducted by Hirsch and Aside from this chronology of symptomsAndersdon, ENG is a helpful examination formulated by Cushing, a thoroughbut is too inconsistent to be useful (Table 5). neurootologic examination will help in theThis patient showed a 50% right reduced early diagnosis of acoustic neuroma.vestibular response. Imaging at this time Presence of neurological findings such aswould be of limited value if the tumor is those presented in this report would stronglyconfined to the intracanalicular region. Most suggest that the tumor has extended to thephysicians routinely request for a CT Scan cerebellopontine angle. Diagnosis at anafter obtaining abnormal audiometric results early stage is desirable using the leastto be able to visualize the presence of the expensive and accurate strategy available.tumor in the CPA but this may not be the Audiometric testing would aid in selectingcase. Enhanced CT scans detect 95% of those patients at high dsk who are thenlarge tumors (>2.5 cm) but small tumors referred for more definitive diagnostic(

inheritance pattern and very high degree of Table I1: Expected Outcome of Audlometric Tests inpenetrance (see Table 1 for the comparisonCochlearVersusRetrocochlear Disorders(Otolaryngology and Head & Neckbetween NF-1 and NF-2). NF-1 areSurgery by K.J, Lee)diagnosed at birth or infancy and almostalways accompanied by skin manifestations,Lisch nodules of the iris, plexiform , CHARACTERISTIC. FINDINGSneurofibroma and distinctive osseous TEST. , COCHLEAR RETROCOCLE_RPure Tone Any configuration Asymmetrical flat Orlesions; all of whichwere not appreciatedin Audio..at../ I?ighfraquencythe patient. NF-2 becomes clinically discrimin Speech .arian Consistent withPTA Not PTA eonsistentwithapparent upon puberty or adulthood. The Speech Little Pl reliever Marked PI rallOverdiscriminationinternal auditory canal shows marked pertormanceenlargementand bony erosion. NF-2 are intensiVr°ll°verDipIscu_s Present .A.bsentlarger in size, multilobulatedand surroundAuditoryrecruib'nentAlternate binaural Prasent Abeentrather than displace facial and cochlearIoudne=balancenerves. Most comfortable Low sensation lever Normal or elevatedand Ioudn_s sensabon leveldiscomfort levelHistologically, a neurofibroma Aud*tory adaptation; Absent or mild >25 dB from initialbegins as an increasingendoneural matrixtone decay test thresholdSuprathrashold Pemeptionoftone Perceptionof;_on_"that spreads Schwann cells apart causing adaptationte_tpersists for60 Padee within 60seoonds_... s de.them to become elongated, tortuous andBekesy'audiometryConventional T),pe I or II Type'lll or IVincreased in number. A schwannoma, on Forward-reverse Overlap offotward-" Separatlonofthe other hand, begin as confined local frequency reverse frequency tracingstracinss .growththat compressesthe adjacent axons Bek_y com_fortable Overlap of pulse- Separation ofaround its peripheryas it expandswithinthe Jeudne= c.pntinuouatrecings t.m.c.ingaImpedance Present at low Elevatd thresholds,perineurium. Typical microscopic audiomatry: sensalJon level: acoustic reflexappearance of ANs has two distinctcellular aeoustio absentwithpuratone Iot,s >85 dBdecay or abseotcharacteristics either Antoni type A (tightly Batterytaat ....... Positive results .... Positive resultsindicating cochlear indicatingpacked) and/or Antoni type B(Ioosely lesions are usually ratrocochlear lesionoacked/,du=te consistentTotal or near-totalremovalis muchmore difficultin bilateral tumors. The best ratraeochlearlesionstreatment approaches are still beingdebated. The surgical approaches currentlyused are: middle cranial fossa,may be consistent:mixed eochlearretroeoehlearpatterns tend toindicatetranslabyrinthine,suboccipital- -- "and combined TableII1:AcousticReflexArctranslabyrinthine-retrosigmoid approaches.Clinical observations suggest though thatregrowth is infreo ent______u___. ,_ ._...._;,_;_2--i r........... ,.............................. -.'__' ,'_ i _';'_'_ _i:.l_, _.......... _"_:' _:t,,_..:: ._i..... ,._ _ ......._....... ,,-" ',...!,:!.;;_____._Table I: Comparison Between NF 1 and NF 2 • . _ --_,_':_= i :'.._._','-iincidence 301100,000 3/100,000 : '------_ .................. "": ....."' AgUeof Onset 1_ decade _or 3r_ : ' idecade ............ .$_...... _.Skin Manif_tations . . ...... _............ i .............Cutaneous 95% have >2 Over 30% >1 " ,_..__,:_..:-*- i ;:._.:_::_. _,::,. _ i ...... _,._ i!---_ '_:-.J_i_!, i _,,_.:..;_, _..... ?..:;._._:neurofibromaa _ ...... _ _............. ;.........>5 caf_ au lair Found in most Rare ...............spots::>>:::d:.,_,Intertriginous Usually present Rare &_'._,',x_;, :_::":';";_freckles'_:_:';':_'_Eye Manifestations .....Lisch nodules Present in >90% RareLens abnormalities Not reported Postc_psularcataract. =,50%Bone abnormalities .... Common.CNS TumorsAN None documented Bilateral in 96%Other brain tumors Optic glloma 2-15% 9-100%_G tumor= O_=aaional Common

TableIV:SummaryofAudiometryTestsDoneonthe PatientSUMMARYTEST ' " COCHLEAR RETROCOCHLEAR The case presented hasPure ToneAudiome_ Equivocal. Equivocal demonstrated the symptoms involved in theSpeech Discrimination Test '" /+l disease entity, that of a rare bilateral,uTT,Lmj0a no_tern Equivocal EQuiVocalToneOecay ............ I+) acoustic neuroma in a female patient. AAccus_cR,_sxAuditoryBrair_tem Resl_nSe(+)(+)detailed history, a thorough otologic andneurootologic examination is vital. It isimperative then to mention that in patientsTable V: Relative Sensitivity of Various Tests in presenting with such symptomatology,DetectingAcousticTumors proper ancillary procedures should be"d' utilized and one should have a systematicP;steriorfossaciStemog'rapi_'y ,., _s and orderly approach regarding theC2.mr_uterizedTomography,gascisternography >4 utilization of diagnostic procedures withoutcomputerizedTomography. metrizanidecistemography . ,. >4AuditoryStainstemResponse . 29 compromising the patient. A holisticComputerized Tomoqtaphy, intravenous enhancement 26 approach, therefore, is emphasized by theCombinedAcoust.¢Threshold Decay 2Thresho_dTeneQ?c_y 16 general physicians to be able to realizeAlternate Binaural Loudness Balance 1.5 one's limits. This is applicable even to theBithermalCaloric .... 1.5_;_e_yAudicr.e_y ..... 14 otolaryngologists who still at present haveShort tncrsmentSensitivi vlndex 1.4" difficulty in the evaluation and managementPlainX-ray 1.3Speech Discrimination,_or_ 0,6 of such cases.Tomography 1.8BIBLIOGRAPHYTableVh ReceiverOperatingCurves(ROC's)forNeurodiagnostic Proceduresin 1. GL Adams, LR Boies, PA Hilger.Diseases of the InnerIdentification of Eight Nerve Pathology ear. In Boeis Fundamentals of Otolaryngology. WBSaunders Company. 1989: 125,133,' :..:.::i:: :. 2. SH Selesnick. RK Jackler. Clinical manifestations andaudiologio diagnosis of acoustic neuromas. In"_'_ Otolaryngologic Clinics of North America. Philadelphia;::_:: ............ ii:_. _ _ _ _'-r¢. _ Saunders, 1992: 521-549."_':i_'_'_'_;_"i_- _ 3. M Weaver.SJ Staller.The acoustic nerve tumor. In JLBoston: Little Brown._;_- '¢ :P'---_" -- '_';_'_" _'_ 1 Northern (ed.), Hearing Disorders._. i .'_IF _i:: _N_.,J_,IHC_T"tl 4. WM House, CM Leutje.Acoustic Tumors vol. h Diagnosis._;_" Baltimore. 1979.•_ I:::_: i ff' _:" :!i_:_"i 5. JW Hall. Neurodiagnosis: Eighth cranial nerve,_: ;_ ii ....,_"= _;._J" cerebellopontine angle, and extraaxial pathology, in:_,':: _:,. p,_il _ _':'_'. .:._,_t,;_" Handbook of Auditory Evoked Repsonses.i ,_,,,, . Massachussets: Allyn and Bacon. 1992: 35-418._ il .,_- :_ 6. JD Osguthorpe. Clinical Audiology. In Otolaryngologic._.,._" Clinics of North America. Philadelphia; Saunders. 1991._i;_; _:_._ 7. ME Lutman. Diagnostic Audiometry. In D Stephens (Ed.,Adult Audiology. Butterworth. 1987: 245-268."_!Zt " 8. J Jacobsen. ABR in Eighth Nerve and Low Brainstem-_ ..........................................................................................................................! Lesions. In the Auditory Brainstem Repsonse. Texas:Pro-Ed. 1985; 184-185._ ':_: _i_ :_:i :'.i_'_ 9, RM Irving, DA Moffat, DG Hardy, DE Barton, JH ×eureb,ER Mahey. Molecular Genetic Analysis of the Mechanism_._._'_!"[:"_: of Tumorigenesis in Acoustic Neuroma. Archives ofOtorhinolatyngology-Head & Neck Surgery 1993; 119;1222-1227.10. JB Nadol, WM Montgomery, HF Schuknechl, RL Martuza.Table VII: Some Major Studies Indicating the Bilateral Acoustic Neurofibromatosis (NeurofibromatosisSensitivity of ABR for Confirmed Type 2): A disorder distinct from Yon RecklinghausensAcoustic Tumors and False Positive Rate Neurofibromatosis (Neurofibmmatosis Type 1).Annals ofOtorhinolaryngology 1991; vol 100; 830-834.as Tested on Various Cochlear Lesions 11. RT Miyamoto, RL Campbell. KL Hoes, RM Worth..... Contemporary Management of Neurofibromatosis. AnnalsHit Rate False Positive of Otorhinola_/ngology 1991; 100; 38-43.Sslte'rsand 1979 _)_.7%(n=94] 8% *in=_66) 12. MS Zavalla, NV Martinez et al."Huge Lesion with SilentBrackmannClernisand "1979 92,0% (n=29) '33% "(n=115)Manifestations", Sept. 1994. unpublished.McGeeGlasscocket =1, 197_ " '98.0% (n=49) "/%"*i'n=399)Harker 1980 94.6% In=3_ ,..9% (n=111)Eggermontet el. 1980 95.0% (n=36_Terkildsenstal. 1981 96.0% _n±5_. 9% {n=711Bauch etal, 1982 96.0% (n=26) ,..25% {n=229I•- approximated

COMPARISON OF FINE NEEDLE ASPIRATIONBIOPSY AND FROZEN SECTION IN THEDIAGNOSIS OF PAROTID GLANDNEOPLASMS*JOSE ANGELITO U. HARDILLO, M.D.**TERESA GLORIA-CRUZ, M.D.**RAMON ANTONIO B. LOPA, M.D. **JOSEFINO G. HERNANDEZ, MD.***ABSTRACTThis study compared the diagnostic accuracies of preoperative fine needle aspirationbiopsy (FNAB) and intraoperative frozen sections (FS) with the histopathologic diagnosis of 52patients who underwent parotidectomy for parotid tumors at the Department of ORE UP-PGHfrom 1993 to 1995. FNAB correctly diagnosed 9/14 malignant tumors (sensitivity of 64%) and38/38 (specificity of 100%). FS, on the other hand, correctly identified 12/14 malignancies(sensitivity of 86%) and 38/38 benign lesion (specificity of 100%). Accurate histologic diagnosiswas made in 46/52 specimen (88%). Error in diagnosis was noted in 5 FNAB and 2 FS readings.Positive predictive values for both diagnostic tests were high at 100%. Over all accuracy was90% for FNAB and 96% for FS.Keywords:FNAB, Frozen Section, Parotid NeoplasmsINTRODUCTIONneedle aspiration biopsy (FNAB) and frozensection (FS) diagnosis.Parotid gland neoplasms are themost common types of salivary gland tumorsFNAB was first developed in theaccounting for approximately 80% of Scandinavian countries during the 1950s.salivary neoplasms. Of these neoplasms, The technique consists of infiltration of a80% are benign while 20% are malignant, gauge 22 needle into the mass andobtaining a tissue aspirate with theThe surgical therapy of parotid application of negative pressure. Thegland neoplasms is complicated by the aspirate is then fixed to a glass slide in 95%presence of the facial nerve and its ethly alcohol. The risks of tumor seedingbranches which run through its substance along the needle tract and facial nerve injuryforming the so called pes anserinus. For is minimal. However, this technique requiresbenign lesions, the facial nerve is spared an experienced cytopathologists well versedduring surgery but for malignant lesions, the in salivary gland pathology. The difficultiesdecision to preserve or sacrifice the nerve lie in the not infrequent pleomorphicdepends on the particular histology and structure of salivary gland tumors, thedegree of differentiation of the tumor as well possibility that the aspirate obtained is notas the intraoperative findings. A representative of the .tumor and thepreoperative histopathologic diagnosis inexperience of the cytopathologist.greatly aids in surgical decision making. Sismains in 1980 reported an 82.8%concurrence between FNAB and finalThe various diagnostic techniques histopathologic diagnosis.include open incisional wedge biopsy, fine* 3rdPlace, PSO-HNS Analytical ResearchDecember 5, 1995, Hotel Nikl_oManila Garden, MakatiCity**Resident,Departmentof Otorhinolaryngology,Universityofthe Philippines-PhilippineGeneral Hospital**Consultant,Departmentof Otorhinolaryngology,Universityofthe Philippines-PhilippineGeneral Hospital

Open incision wedge biopsy is malignant in the statistical analysis. FSanother diagnostic technique available for results were classified as benign orthe surgeon. Its advantage lies in its being malignant. The sensitivity, specificity,able to obtain sufficient tissue for accuracy, and predictive values of FNABhistopathologic diagnosis. Its disadvantage and FS were obtained by comparing themlies in its being an added operation with with the final histopathologic diagnosis.consequent risks of tumor bleeding, seeding Sensitivity is defined as the probability that aand possible facial nerve injury,malignant neoplasm will be identified giventhat a patient has cancer as determined byThe advantage of intraoperative FS the final histopathologic examination (Truelies in its being able to harvest Positives / [Truepositives + Falserepresentative tissue for examination. Negatives]). Specificity is defined as theHowever, there is always the possibility that probability that a benign lesion will bea frozen section diagnosis may be diagnosed given that the patient does notambiguous leaving the surgeon with no have cancer (True Negatives / [Falsechoice but to proceed with conservative positives + True Negatives]). Positivesurgery and wait for the definitive histologic predictive value is the probability that adiagnosis,person has a malignant neoplasm given thatthe test is positive for malignant neoplasmIn comparing these diagnostic, (True positive / [True positive + Falseprocedures, 52 patients who underwent positive]). Negative predictive value is thepreoperative FNAB and intraoperative FS of probability that the patient does not haveparotid neoplasms were studied to gain cancer given that the test is negative (Truemore insight on the strengths and negative / [True Negative + Falseweaknesses of these procedures and Negative]). The overall accuracy representshopefully resolve the uncertainties in their the combination of both sensitivity anduse in the diagnosis of parotid gland specificity (True positives + true negatives/neoplasms.[True positives + false positives + Falsenegatives + True negatives]).SPECIFIC OBJECTIVEThis study aims to determine theRESULTSsensitivity, specificity, accuracy andpredictive value of FNAB and FS compared Demographic Data:with the final histopathologic report in thediagnosis of parotid gland tumors.A total of 52 patients were includedin this study. Their ages ranged from 14 toMATERIAL AND METHODS 78 with an average of 46 years. Themale:female ratio was 24:28. The surgicalA total of 52 patients requiring procedures performed were superficialparotid surgery either for a presumptively parotidectomy, subtotal parotidectomyandbenign or malignantlesionwere includedin total parotidectomy with or without facialthis study. On initial consult, a complete nerve sacrifice.history and physical examination was donewith emphasis on the ENT examination.FNAB was performed after securing FNAB and FS Accuracy:informed consent. The patients thenunderwent definitive parotid surgery guided' FNAB specimens were obtained inby the clinical and histologic diagnosis 52 patients. As shown in Table 1, 9 of 14provided by the FNAB. intraoperatively, malignant tumors (sensitivity of 64%) and 38representative specimens were sent for FS. of 38 benign lesions (specificity of 100%)The entire surgical specimen were sent for were correctly identified. Exact histologicdefinitive histopathologic examinations diagnosis was made in 47 out of 52independently conducted by two specimen (78%). The overall accuracy ofpathologists blinded to the FNAB and FS FNAB which is defined in this particulardiagnoses. FNAB results were grouped into study as its ability to correctly identify benignbenign, malignant and suspicious for and malignant lesions was 90% (Table2).malignancy. The lesions classified assuspicious for malignancy were considered

Table1. CorrelationbetweenFNABand Final identified by FNAB (table5). Again in noHistopathinstancedid a reading of malignancyturnFI_ABout to be benign on final histopathologicFinal 'l_'umberofHistopath CasesMalignant Benign examination (Positive predictive value of100%).Ma!!gnan!. ' (14)Benign (38.).90538 Table4. Correlationof FrozenSectionand FinalTotal (52) 9 43 HistopathFSTable2. Diagnostic Accuracy ofFNABandFS Final NumberofHistopath CasesMalignant Benign....FNAB FS .._ Malignant (14) 12 .... 2Accuracy" ""Sensitivity90%64%.. 96_%.86%BenignTotal(38)(52)0123840Specificity. .....Positive100%100%100%100% Table5. ErrorAnalysisofFrozenSectionBiopsyPredictive ValueNegative 88%..... 95% FalseNegativesPredictive Value FrozenSectionBiopsy FinalHistopathExact tissue 78% 88% 2 Benignmixedtumor MuooepidermoidDiagnosisFalsePositivesNonecarcinoma ,Five malignant lesions wereincorrectly identified and these included Comparing these statistics, itthree muco-epidermoid carcinomas, one appears that the overall accuracy of bothmalignant mixed tumor and one squamouscell carcinoma all of which were read asdiagnostic modalities are high at 90% and96% for FNAB and FS, respectively. FNAB,pleomorphic adenoma on FNAB (Table 3). however showed a slightly higher falseThe negative predictive value was 88% negative rate as reflected in its lower(table 2). In no instance did a biopsy reading sensitivity of 64% compared to that of FSof malignancy turn out to be benign on having a sensitivity of 86%, suggesting thathistopathologic examination, yielding a verybetween the two procedures FS has ahigh positive predictive value of 100% higher abilitytodetectmalignancy.(Table2). Both FNAB and Frozen Sectionshowed 100% specificity and 100% positiveTable3. ErrorAnalysisofFNABpredictive value. This is explained by theabsence of any preoperative reading ofFalseNegative ._. malignancy that was eventually read asFNAB FinalHistopath benign on final histopathologicexamination3 Benignmixedtumor Mucoepidermoid .....carcinoma for this particular series. The negative1Benignmixedtumor malignant mixedtumor predictivevalue of FNAB (88%) was lower1Benig.n.mixedtumor Adenoidcycticcarcinoma , than that of FS (95%) as more FNAB......... specimens (total of five) that were read asFalsePositivebenign turned out to be malignant on finalNonehistopath as compared to two incorrectlyWhen FS results were analyzed, diagnosed FS specimens.twelve of fourteen malignant tumors(sensitivity of 86%) and 38 of 38 benignlesions (specificityof 100%) were correctlyDISCUSSIONidentified (table4). Overall accuracy of This study aims to gain some insightsintofrozen section was high at 96%. Exactthe strengthsand weaknessesof FNAB andhistologicdiagnosiswas made in 50 out ofFrozen Section Biopsy particulady the52 specimen(88%), ('rable2). accuracy of these modalities in thediagnosisof parotidgland neoplasms. BothError in diagnosiswas made in two diagnostic modalities require considerablemucoepidermoid carcinomas which were skill in performing the procedure and inthought to be pleomorphic adenomas evaluatingthe cytologicmaterial. Diagnosis(Negative predictivevalue of 95%), These of benign lesions such as benign mixedtwo specimens were also incorrectly tumorsand mucoepidermoidcarcinomahas

een based on tl_e identification of cytologic to verify in paraffin sections and more so infeatures and architecture such as the FNAB and FS. Between the two procedures,presence of epithelial and mesenchymal FNAB showed a higher false negative rateelements for benign mixed tumors and the thus a higher tendency to miss apresence of mixed epidermoid and mucus malignancy. The complexity and variety ofsecreting cells for mucoepidermoid the morphologic patterns seen in salivarycarcinomas. These diagnostic criteria are gland tumors and the minute amounts ofstill followed despite the fact that these FNAB specimens contribute to the so calledfeatures may not always be displayed sampling error that is inherent to theconsistently in either FNAB or FS procedure.specimens. The pathologist is often forcedto utilize these diagnostic criteria which have Error analysis of FS showed twobeen established for paraffin sections. Also, false negative diagnoses. To determinedecisions as to whether there is capsular whether the FS reading resulted in a lessinvasion or vascular invasion, which already than adequate surgery, these two cases,provoke controversy in paraffin sections, are despite the FS results, both underwent totalamplified in FNAB and FS specimens, parotidectomysuggestingthatintraoperativeDespite these limitations, the present study clinical impression still plays a role inindicates that both modalities have high determining the extent of surgery.overall accuracy rates. The overall accuracyof FNAB was 90% with 100% positivepredictive value and 88% negative predictive CONCLUSION AND RECOMMENDATIONvalue. Sensitivity was 64% and specificitywas very high at 100%. These results One of the most pertinent questioncompare well with other series which that should be answered by the study isreported overall accuracy rates of beyond whether information gained by FNAB and/or85%. The present study is comparable in FS is of any significance in the managementnumber of patients and results with the of patients with parotid neoplasms. Thisseries of Cross et al whose overall accuracy experience indicates that FNAB resultswas 96% and whose positive and negative should not only be used as a basis forpredictive values were 100% and 95%. operating or not but should also beemployed in intraoperative decision making.Both FNAB and FS, as shown in It is further recommended, based on thisprevious studies, are more accurate in the high positive predictive value, thatevaluation of benign salivary gland tumors, intraoperative FS can be disregarded givenIn this series, a 100% specificity and 100% a preoperative needle aspiration biopsy thatpositive predictive values were obtained for is positive for malignancy. However,both procedures. This clearly suggests that because of the higher tendency of the FNABbenign parotid lesions would rarely be to miss malignancy as seen in its lowermistaken for a malignancy using either of negative predictive value, the use of FS isthe procedure. As such a malignancy recommended in cases which are benign ondetected by FNAB and or FS can be FNAB but are suspiciously malignantregarded as true and correct. A negative clinically or intraoperatively.result, however, is more problematic. Erroranalysis of both modalities showed atendency to under report malignancy. The BIBLIOGRAPHYsame trend has been observed in otherstudies for mucoepidermoid carcinoma and 1. Bibrklund A, Eneroth CM. Management ofacinic cell carcinomas. * Parotid Gland Neoplasms. Amer. J. Otol.1:155, 1980.The failure of both FNAB and FS to 2. Thawley S, Panje W. ed. Comprehensiveidentify these tumors can be attributed to at Management of Head and Neck Tumors.W.B. Saunders: Philadelphia: 1987.least two factors, namely, grading--- 3. Swoboda H, Franz P. Salivary Glandmucoepidermoid and acinic cell carcinomas Tumors. Clinical Aspects and Therapy.can be high or low grade and the cytologic Radiologe. 34(5). 232-8, 1994.diagnosis of malignancy in low grade tumors 4. Sismanis A, Strong MS. Fine Needleis less likely--- and invasiveness as a Aspiration Biopsy Diagnosis of Neckmeasure of malignancy, since capsular Masses. Otol. Clin of North Amer. 13:421,and/or vascular invasion is already difficult 1980.

5. Research PrOtocol (3uldellnes 1-orPhysicians. Clinical Epidemiology Unit of theDepartment of Medicine. University of thePhilippines (publisher).6. Rodriguez HP, Silver CE Fine NeedleAspiration of Parotid Tumors. Amer. J. ofSurg. 158:342-344, 1989.7. Zurrida S, Loredana A. Fine NeedleAspiration of Parotid Masses. Cancer.72:2306-11, 1993.8. Cross DL, Snasler TS. Fine NeedleAspiration and Frozen Section of SalivaryGland Lesions. South-Med J 83 (3);283-6,1990.9. Heller KS, Attie JN. Accuracy of FrozenSection in the Evaluation of Salivary Tumors.Amer. J. Surg. 166(4):424-7, 1993.

EPISTAXIS AND HEADACHE IN A PATIENT WITHNORMAL ENT PHYSICAL EXAMINATION FINDINGS(A CASE OF SPHENOIDAL CARCINOMA)*JAIME M. TALAG, M.D.**JOSEFINO G. HERNANDEZ,M.D.***ABSTRACTThis paper reportsa case of recurrentepistaxis in a 58 year old male with associatedexcruciating headache, right sided, frontal in location. Initialconsult with an ophthalmologistsrevealedessentiallynormalfindings.Sinusitiswas the impressionof an internistand neurologistbut ENT examinationrevealed unremarkablefindings.Two weeks PTA, ptosisof the dght eyeand rightsidedfacial numbnessdevelopedand an MRI of the brainwas requested. MRI revealedenhancing mass in the central skull base. Considerationswere chondrosarcoma; chondromametastatic;sphenoidsinusitis.CT scan of the paranasalsinusesrevealed sphenoid sinus mass,probablycarcinomawith contiguousextensionto the cavernoussinus. A right sphenoid biopsyvia nasal endoscopy was performed which documented the diagnosis of squamous cellcarcinoma,sphenoid,moderatelydifferentiated.Presently, the patient is undergoing radiotherapy and chemotherapy with resultantimprovementof ptosisand limitationof ocularmovement.Keywords:Epistaxis,excruciatingrightsidedheadache,skullbase newgrowthsphenoidcarcinomaINTRODUCTIONepistaxis, amounting to approximately 1 tsp.per episode which stopped spontaneously.Some symptoms are commonly of Five months PTA patient consulted anbenign etiology such that physicians would otolaryngologist and patient was cleared.rather think that patients having these Two months PTA severe excruciating rightsymptoms are afflicted with benign problems sided frontal headache started to developrather than a dreaded malignancy, in many lasting for 2-3 hours which spontaneouslyinstances, physicians would tend to disappeared even without the intake ofdisregard the patients complaints even if not medications. Persistence of the headacheall the diagnostic possibilities are exhausted, prompted patient to consult anIt is, therefore, the objective of this paper to ophthalmologist whose findings wereincrease the doctors awareness that serious essentially normal. Consult with an internistpathologies may exist in patients was made and diagnosis was sinuscomplaining of common symptoms even if infection. Patient was prescribedphysical examination findings are negative, medications which however, afforded noThis is one such case.relief. Three weeks PTA patient consulted aneurologist who also diagnosed it assinusitis and advised nasal irrigation.CASE REPORT Consult with an EENT specialist, whosefindings were unremarkable, was made andThis is a case of a 58 year old male, the prescribed oral medications temporarilywho presented with excruciating headache, resolved the headache.Two years PTA patient developed on and off"Presented,PSO-HNS Clinical Case Report ContestApril 7, 1997, Subic International Hotel, Olongapo City**Resident, Department of Otorhinolaryngology,MedicalCenter Manila***Consultant, Department of Otorhinolaryngology, MedicalCenter Manila

Two weeks PTA, upon waking up these causes are not present in the patient,patientnoted presenceof ptosison the right who presentedwith a 2 year durationof onand rightsided facial numbness.The EENT and off epistaxiswhichstopsspontaneously.specialist gave steroids and requested a Nasopharyngeal carcinoma is also aMRI of the eye but a doctor relative of the possibility. However, posterior rhinoscopypatient suggested an MRI of the brain did not show any lesion. A nasopharyngealinstead since patientis also sufferingfrom carcinoma resulting in epistaxis should besevere headache, The EENT specialist large enoughto be visualized,Therefore, inacceded. The MRI revealed an enhancing the absence of a nasopharyngeal lesion,mass in the central skull base to consider NPCA could be ruled out. But the 2 yearnewgrowth as in chondrosarcoma, durationof epistaxisshould be a cause forchordoma, metastasis.Anotherpossibilityis alarm. Fungalsinusitisand paranasal sinus' an inflammatory process involving the carcinoma can present similarly withsphenoidsinus.Patientwas then referred to epistaxis,and, as long as there is no bonethis service and was advised to have CT involvement, physical examination will bescan of the paranasal sinuses which essentially normal. Radiologic evaluationrevealed sphenoid sinus mass, carcinoma could have provided important informationwith contiguous extension to the cavernous about the sinuses at an earlier time. Andsinus and was subsequently admitted,haziness of the sphenoid sinus alone in theabsence of problems on the other sinuses,On physical examination, should point to the possibility of a seriousophthalmologic findings revealed ptosis of pathology.the right, pupil dilated 5 mm, non reactive tolight, visual acuity of 20/30. There was Two months PTA, the patientlimitation of movement in all quadrants and started to develop excruciating right sidedfundoscopic examination was essentially headache. Consult with an ophthalmologistnormal. There were normal findings in the likewise cleared the patient of any eyeleft eye, and with essentially normal ENT pathology The right sided excruciatingfindings, headache persisted which promptedconsults with an internist and a neurologist.With no localizing sign, the neurologistOPERATIVE NOTES cleared the patient and advised noradiologic evaluation even though thePatient underwent right sphenoid problem was attributed to a sinus infection.biopsy via nasal endoscopy. Nasal findings Headache could be secondary to a numberwere essentially normal except for slight of causes from a benign tension headachemucosal bulge at the upper septum on the to a formidable malignancy. In this patient,right side. Right anterior sphenoid wall is the lesion initially involved the sphenoidunremarkable. The posterior 1/3 of the sinus and definitely no neurologic sign andmiddle turbine was removed in accordance symptom was present. After progressing inwith the Wigand approach to the sphenoid size and resulting in bone destruction, thesinus. The anterior sphenoid wall was barrier to its extension intracranially hasopened. A solid mass was noted to be been destroyed. The excruciating headachefriable. There was mild to moderate could be secondary to involvement of thebleeding. Nasal packing was done.dura. Plain sphenoid sinusitis can result inheadache usually occipital but definitely lesssevere, The presence of the excruciatingHISTOPATHOLOGICAL RESULTheadache inferred that problem could besomething else and not a simple case ofSquamous cell carcinoma, sphenoiditis.moderately differentiated(Sphenoid)It would be advisable that, inpatients with seemingly benign symptoms,DISCUSSION care should be done to exhaustivelyevaluate these symptoms especially whenIt is true that a big percentage of physical examination reveal no otherepistaxis is of benign etiology. More abnormality, Radiologic evaluation couldcommoncausesof epistaxisincludetrauma, show haziness of the sinus involved.ACTsinus infectionas well as hypertension.All

Table 4 (see appendix) gives the Table 6. NumericalParametersValuesto Predictfor theSnorersAnthropome[ricanthropometric data of snorers and nonsnorers.The mean values obtained from Anthropometric Numericalmeasurements of the oropharyngeal Par.met_ Valois(ram)MaleFemalestructures showed good correlation with Uvu_a_en_th U_ 714 _1_snoring. Of the six anthropometric variables,only four were found to differ significantlybetween snorers and non-snorers. TheseDistance bet ante_orIpII/ars AP

and the area from the soft palate toposteriorpharyngealwall (50%). Most (90%)Snoring is common, estimated toof the non-snorerswere correctlypredicted be present in as high as 25-45% of thein all fourout of four parameters, population.8 Variousauthorsnotedthat 20%of males and 5% of females snore at theTableS. Frequency Distribution ofCombinedAntbropornelric Variablesage of 30 years with a dramatic increaseto60% males and 40% females who snore atu_AnthropometricVariable Frequency4(2o_)60 years of age.1° In this study, 7.7% ofmales and 5.9% of females were found toUI+UP 3(15%)pP+uP 2{lO_) snore at the age of 30 years and theseuP 2(lo_) proportions increased to 41% of males andUI+AP+UP 1(5%)u_+PP 3(_s%) 41.2% of females who snore at the 6th, UI+PP+ ,UP2(_o%} decade of life. Neither a symbol of goodUI+AP+PP 1(5%)o2(_}_1 ...... health nor a physiologicalrespiratorysound,Toter 20 snoring describesa partial narrowing of theupper airway particularly the oropharynx,and frequently involvesthe velopharyngealDISCUSSIONsphincter and tongue base.3'4'5As part of adisease continuum known as obstructiveNormalbreathingresultsfrom nerve sleep apnea (OSA), snoring is regularlysignals that come from the brainstern associatedwith OSA patients(89.6%) fromcausing the diaphragm, the chestwall or the Sleep Disorders Laboratory of St. Luke'sintercostal muscles and pharyngeal muscles Medical Center, Phil. and 94-100%_1fromto contract. These signals result in muscle foreign literatures diagnosed bycontraction of the diaphragm and intercostalmuscles to increase chest contraction ofpolysomnography.pharyngeal muscles that hold the pharynxOSA signifies a severe narrowing ofoPen-ethe pharynx resulting in a complete block tobreathing during sleep, it is defined as aThe brain which is sensitive to cessation of airflow at the nostrils andchanges in 02 and CO2 levels in the blood mouth for at least 10 seconds7 and isduring waking hours becomes less sensitive diagnosed by polysomnography12'13OSA isduring sleep.' As a result, muscles become measured by apnea index which is definedrelaxed but remain sufficiently active to as the number of apnea per hour of sleepmaintain ventilation. The muscles around and where a finding of apnea index > 5 isthe pharynx relax making the walls floppy diagnostic. Clinical manifestations includeand collapsible, This already narrowed snoring, excessive daytime sleepinesspharynx plus an increase in the negative (EDS), apneas/choking,morningheadache,pressure when breathing in may suck the intellectual deterioration, personalityfloppy walls making it narroweror partially changes, behavioral disorders, restlessblocked generating the noise known as sleep, bedwetting,breathlessnessat nightorsnoring.Fairbanksand Fujita notedthat thenoise in snoring and OSA is generated byday, decreasedheartburn.sexual activity, andair turbulence within the collapsible part ofthe pharynx&9 Rice traced its exact sourceObstruction typically begins in theto the vibratin_ soft palate and posterior oropharynx with the tongue contacting thetonsillar pillars.'_ Compliance of the walls of soft palate and posterior pharyngeal wallthe pharyngeal airway is quite variable, followed by progressive collapse of lowerdepending on local factors and most pharyngeal airway. When airflow isimportant, the tone of the musculature of decreased or absent for a few seconds, thethe pharynx. Any lesion that can increase body's defense mechanisms are alerted asthe resistance to airflow would necessarily the changes in the blood 02 and CO2 levelsincrease the amount of effort required to stimulate the brain to cause arousal frommaintain airflow. Remembering the sleep and increase ventilation. (Figure 4).Bernoulli effect, this would increase the Apnea-arousal pattern disrupts a night'snegative intraluminal pressure further and sleep. If untreated or unrecognized,the airway thentendstocollapse, repetitive nocturnal O2 desaturation can

potentially produce significant social tongue simply appears too large for theconsequences and serious medical mouth in these patients.complications or even death. 1'2'31"_ Themedical conditions associated with snoring Aside from thyroid hormones, sexinclude hypertension, myocardial infarction, hormones are believed to play an importantincreased risk of brainnfarction, cot role in the development of snoring andpulmonale, gastroesophageal reflux, OSA. Sixty-nine percent of snorers in thisnocturnalngina, cardiac, arrhythmia, sudden investigation were men attesting to the factdeath during sleep, and OSA. that not only does snoring and OSA occurpredominantly in men, but high levels ofFigure 4. Diagram Bhowing Effect of Oz and CO2Changes testosterone have also been associated withits development. This is due to thehormone's effect on muscle strength and fatAIRFLOWldecreaseddistribution wherein men tend to gain weightaround their neck and abdomen whilewomen around their hips. In contrast,CHANGEin O and CO levels progesterone which is known to stimulateventilation may contribute to increasedBrain stimulated to wake up frequency bf disordered breathing duringsleep in premenopausal women. 716Allows return ofstrenj_th-- torelaxedmusclesChange in muscle tone could be anThroat opens_l'toallow airflow age-related reduction such that patient withmild snoring may advance to severe snoringor even to OSA through a deterioration ofPredisposing factors commonly implicated competency of protectivefor worsening an already existing upper neurophysiological mechanism. Drinkingairway abnormality during sleep include: alcohol and taking sedatives cause greatermuscle relaxation during sleep than1. endocrine disorders such hypothyroidism normally occurs and, hence, can result in anor acromegaly abnormally collapsible airway It also2. obesity particularly around the neck decreases arousal responses and when3. change in muscle tone which may be excessive may also damage nerve. Theseage-related reduction in muscle tone or due may also explain the reason for anto neuromuscular disorder, or to CNS increased risk of snoring in males especiallydepressantsin heavy drinkers.4. upper airway abnormality which mayinvolve air passage anywhere from the Upper airway abnormality maynose to the pharynxinvolve multiple sites from the nose down tothe hypopharynx. The sites most commonlyObesity is the major disorder documented have been located in theassociated with snoring and OSA. Obese oropharynx and frequently involves thepeople are found to be three times more velopharyngeal sphincter and the tonguelikely to snore. 16 Thawley observed that base. 3'45 Clinical disorders associated withapproximately 70% of patients with snoring structural narrowing of the airway includeand OSA are 15% heavier than their ideal nasal problems, adenotonsillar hypertrophy,body weights and a significant number have low-hanging soft palate, long edematousshort, thick necks with excessive cervical uvula, prominent tongue, pharyngealtissue. The results of this study reveal that neoplasm, macroglossia and micrognathiaabout 57% of snorers were more than 15% which clearly predispose-a person to theover their IBW, of which 14% were morbidly development of snoring.obese, i,e. twice the IBW_ Frequently, thesepatients have an excessive amount of tissue Evaluation of the possible causes ofin the oropharynx characterized by a low- snoring and OSA should includehanging redundant palate, large tonsils, examination of the oral, nasal, pharyngeal,excessive pharyngeal folds, and a small laryngeal and neck areas. Routineoropharyngeal orifice. Commonly, the procedures to assess potential sites of

airway compromise currently used in most selection of the appropriate surgicalcentersinclude:procedure for effective control of snoringand OSA. Since its introductionin 1952 by1. complete otorhinolaryngologicalhistory Ikematsu,t7 uvulopalatopharyngoplastyand physicalexamination (UPPP) has been demonstrated to2. fiberoptic nasopharyngolaryngoscopy effectively treat approximately 50% ofwithMuellermaneuverunselected cases with snoring and OSA.3. Cephalometdc analysis which includes The procedureinvolves the partial excisionthe upper airway, soft tissue x-rays in of the soft palate and uvula (Figure 5). Thethe upright and supine positionduring resectionof the soft tissues is extended tothe inspiratoryand expiratoryphase the tonsilsor the tonsillarbed togetherwithof respiration (Dynamic the anteriorpillars.The posteriorpillarsareCephalometry)CT Scan may also preservedand mucosalclosureis done withbe used, though,in selectivecases absorbablesutures.Efforts have been madeonly since it is too expensivefor a to identify preoperatively those likely toroutineprocedure,benefitfrom the procedureand priorauthorsnotedits effectivenessin treating snoringinThe treatment of the health issues as highas 90% inthose whose major airwayin snoring patients may be categorized into compromise is in the oropharynx,t5 Thesurgical and non-surgical modes. At failure of uvulopalatopharyngoplasty topresent, there are at least 300 devices in correct or treat snoring in some of thesethe United States Patent Office claiming to cases underscores the fact that though thecure or eliminate snoring, but the success velopharyngeal sphincter is the mostrates of these devices have been estimated common site of obstruction, other sites into be rather low.t5 (Table 9)outlines the the oropharynx may be responsible andnon-surgical treatment options for snoringand OSA.Table g. Non-surgical Treatment Options for Snoring.141. Exercisemust be considered. More importantly, itmay be due to over-or under- estimation ofmargin of resection.2. Weightloss .,_"_"%_.,-"---d,oo,i,u .*' j, .... "'_-,..-3. Elevationof the headofthe bed /- ..... _,._.o;;n=_. / .... _...... _'% .4. Avoidanceofalcoholandothersedatingdrugs _ _' _"'_'i""'_d ,_,,e /' ":"_:_"""'_ """_'=" ....5. Ear plugsfor bed parlners | (_ __,- ' _;.... | ;7"_,,_:_,, _/' '_.! i7, Dental appliances to reposition tongue and or _.._ .... __,_!,/,_, %_._ ._. _ .,/'8. CPAP ,9. Nasopharyngealtubesor catheters p_=,._j..l ......10. Anti-snore pillow A. QOMMON ©AU|OS =P O, MASOIN OP se=eclrooN=NOSING ANO OGA11, Tennis ballsewn intothe backor thenightwear12. Negative reinforcerssuchas electricshocks,vibratingdevice lights,tape recordingfeedback of the snoringsounds. /,_1_:-X'"" . _.x.;..* -:_.,,_.Surgery as a treatment of snoringi "E _|'._/.......•t '_ ..Z./aims to provide an improved pharyngeal \ _,_....._--_//" \ _"_' ..'T"7"", .......airway by eliminatingsources of obstruction _....:Y "_"_'Y :;,"'._,-responsible for generating the snoring ........sound. Surgical treatment options varies '.=°"'_" ........... "" ".""""°" o'"=",==accordingto the patients needs and mayinclude 1) nasal surgery for polyp, septalFlgure S. Uvulopalatopharyngoplasty(gPPP)deviation, or enlarged turbine, 2) To date, the most promisingtonsillectomy and/or adenoidectomy 3) predictiveevaluationtechniqueyet reportedtracheostomy,4) uvulopalatopharyngoplasty is direct endoscopicobservation of airway(UPPP), and recently, 5) Laser Assisted collapse during Mueller maneuver. MuellerUvuloPlasty(LAUP).maneuver is a forced inspiratoryeffort withthe patient'smouthand nose closed. UpperThe pre-operative evaluation of airway observation by flexible fiberopticupper airway abnormalities is vital in the endoscope during Mueller maneuver is

found to be helpful in obtaining qualitative oropharyngeal structures with a stainlessinformation regarding the diameter of the steel two-prong caliper demonstrated fourairway at the velopharyngeal sphincter and anthropometric variables that weretongue base. Though it is difficult to provide significantly different between snorers andquantitative measures in using this non-snorers, namely: 1) uvula length, 2)technique, it is nonetheless an important distance from sift palate to posteriordiagnostic procedure prior to pharyngeal wall, 3) distance between thepalatopharyngoplasty (PPP) as it enables anterior pillars, and 4) distance between thethe surgeon to directly visualize at critical posterior pillars. There was no correlationsites. 9_ between patient's demographic data and theanthropometric parameters inspite of theCephalometric studies as predictors observed age, sex, and weight predilectionof patients who might not respond to UPPP of snorers.due to lower airway obstruction have beenreported by several authors. Riley and co- Numerical values were derived fromworkers have stated that cephalometric the linear regression for these fouranalysis by x-ray studies (Figure 6) parameters (Table 5) separately for bothrepresents the best evaluation of possible sexes due to known anatomical differences.airway obstruction at and below the level of This not only allowed classification ofthe tongue base. A low position of the hyoid subjects into snorers and non-snorers butbone measured cephalometrically correlated also narrowed down the possible sites ofwell with poor response to PPP for snoring oropharyngeal obstruction to the mostand OSA. The distance from the tongue probable ones. As was documented inbase to posterior pharyngeal wall was various foreign literature, this studyevaluated and the pharyngeal airspace was revealed that the most common site ofnoted to be smaller in patients who obstruction involved the velopharyngealcontinued to have OSA following PPP. sphincter, namely the uvula (70%) and theCephalometric studies clearly show the area between the soft palate and posteriorrelationship between position of structures in pharyngeal wall (50%). Two out of the 20the patient and the narrowing of pharyngeal snorers were not predicted to be snorers inairspace which may result from any of the four parameters. This may beabnormalities of craniofacial skeleton and attributed to a different cause of obstructionhyoid bone. other than the four anthropometric variablesmeasured such as narrowed distanceFigure 6. Cephalometry between tongue base and posteriorpharyngeal wall. This parameter was not_:_t would measured give since inaccurate depressing values. the With tongue these;_i_ 'l %;

supine position has been demonstrated to 10. Pelausa EO, Tarshis LM: Surgery foryield more information regarding possible snoring. Laryngoscope 1989;99:1006-airway compromise during sleep. Also, the 1010,use of the derived numerical values as a 11. Goode R: Sleep Disorders.perioperative guide to the extent of surgical Otolaryngology-Head and Neckresection is a promising aspect that must beSurgery1986,(Cummings,ed.);2:1449studied 12. Rosenberg,C: Sleep Studies:BIBLIOGRAPHY Polysomnography.ENT Journa_l1993;72:61-62.1. Maniglia AJ: Sleep apnea and snoring, 13. Brooks L: Diagnosis andan overview. ENT journal 1993;72:16- pathophysiology of OSA in children.19 ENT Journal 1993;72:16-18.2. Fujita, Shiro: UPPP: A new surgical 14. Strohl KP, Boehm KD,Denko CW, et al:approach for treatment of OSA, 193- Biochemical morbidity in sleep apnea.196, New Dimensions in ENT j 1993;72:34-41Otorhinolaryngology-Head and Neck 15. Ejercito VS: Snoring and sleep apneaSurgery 1985 (Myers, ed.); 1;193-196. surgery presented at the Philippine3. Katsantonis GP, Friedman WH, et al: Society of Otorhinolaryngology-HeadThe sugical treatment of snoring: a and Neck Surgery March 1985.patient's perspective. Laryngoscope 16. Redline S, Young T: Epidemiology and1990; 100: 138-140. natural history of obstructive sleep4. Fairbanks D: apnea.ENT Journal 1993;72 20-26Uvulopalatopharyngoplasty: Strategies 17. Ikematsu T: Clinical Study of snoring forfor success and safety. ENT Journal the past 30 years. New Dimensions in1993;72:46-51. Otorhinolaryngology-Head and Neck5. De-Berry Borowiecki B, Kukwa A, Surgery 1985 (Myers,Ed.);1:199-202Blanks RHI: Indications for palato 18. Crumley, RL Stim M, et al:pharyngoplasty. Arch Otolaryngol Determination of obstructive site in1985;111:659-63. obstructive sleep apnea. Laryngoscope6. Hudgel, D: Properties of the upper 1987;97:301-308airway during sleep ENT Journal 19. Riley RW, Powell NB, et al: OSA1993;72:42-45. Syndrome: A review of 3067. Thawley S: Sleep apnea disorders, consecutively treated surgical patients.Update in Otorhinolaryngology-Head Otolaryngology-Head and Neck Surgeryand Neck Surgery 1985 ( 1993; 108:117-12Cumminfs,ed): 1:303-3228. Fairbanks DNF: Snoring: surgical vs.non-surgicalmanagement.Laryngoscope 1984;94:1188-1192.9. Fujita, S: OSA Syndrome:Pathogenesis, upper airway evaluationand surgical treatment. ENT Journal1993;72:67-76.

BILATERAL ACOUSTIC NEUROMA:A REPORT OF A CASE*CLYDINE MARIA ANTONETTE C. GUEVARA, M.D.**MARIO S. ZAVALLA, MD.**FELIPE FEDERICO O. PIO, M.D.**JAIME ANTHONY A. ARZADON IV, M.D.**ANGLE E. MONTEIRO, M.D.**CARLOS P. REYES, M.D.***NORBERTO V. MARTINEZ, M.D.***ABSTRACTAny unilateralhearing loss, tinnitusand vertigo is an acoustic neuroma unless provenotherwise. One should maintain such a conviction in orcler not to miss its diagnosis.Occasionally,the dilemma is compoundedwhen the tumor occurs bilaterallyas seen in 5% ofcases. However,diagnosiscan be arrivedat by performingaudiologicstudies which are readilyavailable. Likewise,imagingtechniqueshave made it possibleto document suspected lesions.A 20 year old female with symptomsof bilateraltinnitus,hearing loss and vertigo is discussed.Neurotologicproceduresconfirmedthatthe patienthas bilateralacoustic neuroma. A systematicand rationalapproachon arrivingatthe diagnosisis presented.Keywords:AcousticNeuroma,VertigoINTRODUCTIONCASE REPORTAccurate identification of an Three years PTA, Vanessa M., a 20acoustic nerve tumor is among the most year old female noted tinnitus and hearingformidable diagnostic problems facing the loss on both ears accompanied by pain ofotorhinolaryngologisL Although classic the right jaw. A general practitionersymptoms of hearing loss, tinnitus and prescribed Carbamazepine and Betahistinevertigo have been well documented, only which afforded no relief of symptoms. Nofew patients fit into the expected picture, diagnosis was given and patientwas lost toTherefore, the clinicianmust be made aware follow-up. Three months later, vertigoof diagnostic misadventures such as the described as a whirling sensation of thecase presented. The bilateralpresentation surroundingsdeveloped. Consult with anof symptoms may have confused the ENT was made and given Flunnarizineandphysiciansand caused a delay inthe proper Astemizole which afforded temporary reliefdiagnosis. Systematicevaluationof eighth of the vertigo but no audiologicwork-upsnerve lesions through audiologic and were requested_ At about this time, anvestibular evaluation constitutes an anterior neck mass developed for whichimportant aspect in the diagnosticregimen diagnosis of Diffuse Non-Toxic Goiter wasfor acousticneuromas. This case will show given and patient was prescribedthe clinician the possibility of an atypical Levothyroxine. One year PTA, patient notedpresentation of acoustic neuromas, the gait problems presenting as a sense ofimportance of a battery of audiometric tests imbalance when walking, in addition to thein early diagnosis and, therefore, earlier previous symptoms. There weremanagement of acoustic neuromas,concomitant symptoms of palpitations, easy"2nuPlace,PSOHNSClinical CaseReportContestApril7, 1995,Subic InternationalHotel,OlongapoCity**Resident,Departmentof Otorhinolaryngology,Sto.Tomas UniversityHospital***Consultant,Departmentof Otorhinolaryngology, Sto.Tomas UniversityHospital

fatigability, fine tremors, weight loss despite a right beating nystagmus when target is ona good appetite, difficulty of swallowing the right while Optokinetic Nystagmussolids and a five month amenorrhea. A revealed asymmetric results. Spontaneousdifferent general practitioner advised that nystagmus showed a right beatingLevothyroxine be discontinued. The gait nystagmus which is still evident on gazeproblem as well as the symptoms of vertigo, evoked nystagmus upon gazing to the dght.tinnitus and hearing loss were attributed to Findings of Fixed Amplitude Saccadethe excessive use of Levothyroxine. Despite Vertical still revealed right beatingthe clinical presentation, no work-ups nystagmus on gaze upwards. On Verticalwhatsoever were requested previously until Smooth Pursuit there was an abnormal4 months PTA, when slurring of speech break of pursuit movement, and thedeveloped. A neurosurgeon, in turn, Optokinetic Nystagmus showed asymmetricimmediately requested for a CT Scan which reading. There was no evident nystagmusrevealed a Bilateral Acoustic Schwannoma, on vertical Gaze Evoked Nystagmus,and was advised surgery. Because of the Stationary Positional and Paroxysmalmorbidity of the said operation, a second Positional (Dix-Hallpike Maneuver). Caloricopinion wassought, testing showed 50% reduced vestibularresponse on the right (Fig. 7). The results ofOn admission, patient demonstrated these procedures are highly indicative of asigns of hyperthyroidism and had a notable retrocochlear disease as evidenced by theanterior neck mass. Neurologic examination CT Scan previously requested whichrevealed an ataxic speech, a drunken gait, exhibited a 5 cm mass on the right and a 1.7dysdiadochokinesia and dysmetria. There cm mass on the left cerebellopontine angleswas a 25% sensory deficit over right half of (Fig. 8). Blood specimen was sent forthe face and a hyperactive reflex was chromosomal analysis to document theelicited. Spontaneous and gaze nystagmus possibility of Neurofibromatosis type-2. Thewith an absent corneal reflex on both eyes results revealed a Normal 46XX femalewas noted. The gag was not elicited. (Fig.9).Vestibular function tests showed a Figure !: Pure ToneAudiogramright swaying Rombergs, Mann's and ,............ _am M,,_ _ ,_ =Untenberger's tests. Tuning fork testshowed a lateralization to the left (better ear) - ' " - "* -- ',' : ,._Lon Weber's test, an air conduction (AC) : . • F_ --greater than bone conduction (BC) on _1_--- " _,Rinne's test and a short tone perception on _ " - 1 it :_....i °both ears (Schwabach's test) when : ,°compared to the examiners. Since no •:: :.: :..: ::!: ....:].. • . . . ..::audiologic studies were done previously, the ,.. : ....... - ,°_'°:: i:i :ifollowing were requested: a pure toneaudiogram (Fig. I) which showed rightmoderate sensorineural hearing loss with Figure 2:SpeechDiscriminationpoor speech discrimination and left normal TEST ,_.T LEFThearing with a dip at the 2000 hz and a 4000 SRT 40dB 25dB ,,hz with good speech discrimination (Fig. 2); P_ MCL 24_ 80 88_ 6_a tympanogram showing type A on both TOL '_00 _ _0_ ' i_ears (Fig. 3); an absent ipsilateral andcontralateral Acoustic Reflex ThresholdFigure3:Tympanogram(Fig. 4); a (+) tone decay on the right ear(Fig. 5); an Auditory Brainstem Response(ABR) which demonstrated a distinct wave Iand the absence of the proceeding waves(Fig. 6), and Electronystagmography j__ j_.._(ENG) revealing the following: FixedAmplitude Saccade - horizontal showed rightbeating nystagmus on looking to the right,Horizontal Smooth Pursuit likewise showed

AESTHETIC NASAL RESTORATION*JACKIE M. MORENO, M.D.**FREDERICK Y. HAWSON, M.D.**RAYMOND VINCENT P. JURILLA, M.D.**EUTRAPIO S. GUEVARA, JR., M.D.***ABSTRACTThis is a surgical case report that presents a modified method of subtotal nasalreconstruction that employs vascularized septal chondromucosal flaps for lining, and conchalcartilage grafts to support the nasal dorsum, replace the missing tip and rim support and foreheadflap replacement of nasal subunits.This method has many advantages. The lining is thin and highly viable. Neither externalshapes nor airway patency is distorted by excessive bulk. Lose of lining, the chief enemy ofnasal reconstruction, seldom occurs because these flaps are highly vascular.Keywords: Nasal reconstruction, septal chondromucosal flapsINTRODUCTIONIt is a tacit promise that plastic fabrication provides projection in space,surgeons can replace a missing nose. This airway patency, support and, when visiblepromise has not been kept. Loss of the through conforming skin cover, the delicateentire nose is unusual in traumatic injuries contour of the normal nose. With this, thebut usually occurs following radical resection need for multiple revisions to sculpt andfor malignant disease. There is an inherent debulk is decreased.desire in human beings to look normal andnot peculiar, horrible, or even different aftera nasal reconstruction. It is well accepted HISTORICAL BACKGROUNDthat reconstructive procedures required forfull thickness defects of the nose include A brief summary of the history of therestoration of the outer covering, the inner art of reconstructing the nose assists one inlining, and the supporting framework, the understanding of the development ofLining, support, and cover do not make a newer techniques. In ancient times,nose. Rather, it is the manner of shaping amputation of the nose was considered aand assembling these materials that give justifiable punishment for a variety of crimes.contour to the lump and the visual In India, dudng Vedic times (2000 B.C. toimpression of a nose. In line with this, a 500 B.C.), the prevailing punishment forbetter technique of nasal restoration was adultery was amputation of the nose. Selfmodifiedto meet this demand, mutilation by cutting off the nose was alsopracticed by women who wished to protectThe aim of this report is to present a their honor by disfiguring themselves asmodified method of subtotal nasal related by Nelaton and ornbre'danne (1904)reconstruction employing the use of thin but during the Danish invasions of England andhighly vascular local lining and cover flaps to France. The use of Forehead flap in nasalallow successful primary placement of reconstruction bears the name of the "delicate cartilage graft. The cartilage Indian Method " by the Koomas of ancient"3r_Place,PSO-HNSSurgicalCaseReportContestApril8, 1995,SubicInt'l.Hotel,OlongapoCity**Resident,Departmentof Otorhinolaryngology, St.Luke'sMedicalCenter***Chairman,Departmentof Otorhinolaryngology, St.Luke'sMedicalCenter

the ear_:v:::!!nasal _.,e@xisti_ucti:6i!i:::::::

.... : : ::::::::::::::::was: made::bigger:so lhat: tS excess ::

attdo:n:e::: ::ie:::::::: !r:al: :........ :: : :: :::::::liiiiri_:fl!i:e:::

:,i::(:i ¸: :i.:::: and fo_ Si_rface:Ot:tt_e nose to bulg e. : ::The b :_[ Pii Of the fiaps is further: :..... ...... iii:_ placed: withiri: a tight : i.....mante: sk uSiia ly: the:] ] :::ic,Ov:e!'nor :a:ps::i,_u.st be lash _le_:ih an: ....d y::"eq{ rec ::to i: :this:: bu _Y_s seceSS aies a_ Itipley ,',eviSions to d scard: lt_e excess :: ::::i:::::::::: .... :: : ssue aid::s:e:C:o:ndaF placement:: (!f: suppOd: ::: :...... _:::::::: :::::::Chondt'_mu:cbgal flaps iI........ ::: eonchaL cartil:age grafls fabricated to suppo_tthe: rtas:al Of:'St:U"n, replace,, mi:ssii_i: tip: and: :..........:::::: :::::=rim: suppell: aild: fol_ehead:flap i;ep_acernel_t:(.iTr_asal::,subui!lii:s has :fTlaiiY advantage=, : :::: ......... iese i_ igS::ai'!e thin ai_d::°e viable, : : [t 7e:: ext:e !'a ,sqapes :aFWay patency:::::::: :::is:disIoi'ted: by :excessive bulk as Cornpared: toot :O:ss of lng :::: the ci of lasa[ :t_ei;ei_struction, : [.... Secoll: because: :these aps are: :[:: [[:[[:: ]

and functionallyrestored nose in a fourthdimension- "BEAUTY".BIBLIOGRAPHY1. Converse, J.M: Full-thicknessLoss ofNasal Tissue. ReconstructivePlasticSumeni Vol 2. Philadelphia, W.B.SaundersCompany,1977, p_1209.2. Millard, D.R., Jr.: Reconstructiverhinoplastyfor the lower half of a nose.PlasticReconstr.Sur_.,53:133, 1974.

ANTHROPOMETRIC MEASUREMENT OFOROPHARYNGEAL STRUCTURES AS A PREDICTOROF SNORING AND OBSTRUCTIVE SLEEP APNEA*EDGAR DE GUZMAN, M.D.**NORBERTO V.MARTINEZ, M.D.***JOY QUE, M.D.****JAIME ANTHONY A. ARZADON IV, M.D.**ABSTRACTTo determine if oropharyngealmeasurement could predict snoring and localize theprobable site/sof obstruction,differencesin the oropharyngealmeasurementsof subjectsseenat the outpatientdepartment of ENT were determined. Phase I.of the study included99 snorersand 56 non-snorersand involvedidentificationof parameters that correlated with snoring andderivationof linearregressionformulae andnumericalvaluesto predictsnoringand the probablesite of obstructiomMeasurementswere correlatedto the occurrenceof snoring and probablesitesof obstructionidentifiedbased on the statisticallytreated data, Of the five anthropometricvariablesmeasured,the followingwere shownto be significantlydifferent betweensnorersandnon-snorers:1) uvulalength(UI), 2) distancefrom soft palateto posteriorpharyngealwall (UP),3) distancebetweenanterior pillars(AP), and 4) distancebetweenposteriorpillars (PP). Therewas no correlation between the patient's demographic data (age, height, weight) and theoropharyngeal measurements. Phase II included 20 snorers and 20 non-snorers and involvedvalidation of linear regression formulae and derived numerical values to predict snoring andlocalize probable sites of obstruction. All had high specificity and positive predictive values withthose for UI, UP, and PP attaining almost 100% specificity and positive predictive values. Fromthe measured oropharyngeal variables, the most common sites of obstruction are the uvula(70%) and the distance between the soft palate and posterior pharyngeal wall (50%). With theseanthropometric measurements, delineation of snorers from non-snorers and localization ofprobable sites of obstruction may be achieved.Keywords: anthropometric measurements, oropharyngeal structures, snoring, obstructive sleepapneaINTRODUCTION poor pharyngeal muscle tone and upperairway abnormalities which may involveSnoring is not funny and must not be multiple sites from the nose down to theregarded as something benign nor trivial, hypopharynx. The sites of upper airwayNeither a symbol of good health nor a obstruction most commonly implicated havephysiological respiratory sound, it signifies a been located in the pharynx and frequentlypartial narrowing of the airway. Probably a involves the uvula-soft palate complex andpre-clinical state for the development of the tongue base.3'4'5Obstructive Sleep Apnea (OSA), it causes Uvulopalatopharyngoplasty (UPPP) as arepetitive nocturnal oxygen desaturation treatment for snoring and OSA is effectivewhich then tends to potentially produce in those whose major airway compromise issignificant social and serious medical in the oropharynx. Pre-operativecomplications.1'_3 Certain anatomical identification of the specific site is crucial infactors contribute to the generation of noise: the therapeutic plan. Routine procedures to"2rid Place,PSO-HNS, Analytical ResearchContest, HotelNikkoManilaGarden"*Resident,Departmentof Otorhinolaryngology,Sto.Tomas UniversityHospital***Consultant,Departmentof Otorhinolaryngology,Sto.Tomas UniversityHospital.... Consultant,Departmentof Anesthesiology, Sto,Tomas UniversityHospital

assess the potential sites of airway regressionlogisticswith age, height,weightcompromise currently used include: 1) as dependentvariable.completeotorhinolaryngologicalhistoryandphysical examination 2) fiberoptic Linearregressionequationformulaenasopharyngoscopy with Mueller's were then constructedusing the identifiedmaneuver and 3) cephalometricanalysisor parameters correlated with snoring. Fromdynamiccephalometrywhichincludesupper the linear regressionequations, numericalairway soft tissue x-rays in the uprightand valuesfor the correspondingoropharyngealsupine position during inspiratory and measurementswere derived to serve as aexpiratory phases of respiration, guidein predictingsnorers.Computerizedtomographyscan, which hasgreater accuracy in localizing sites of - Phase II. Validation of the derivedobstruction,may also be employed but the formulae. Twenty snorers and twenty nonconsiderableexpense it entails limits its snorerswere seen at the same institutionwidespread use. from September to October 1995 andscreened with the same aforementionedThe objectives of this study are: 1) exclusion criteria. They were then subjectedto correlate the various oropharyngeal to the standard otorhinolaryngologicmeasurementswith the presence of snoring, examination and oropharyngeal2) to determine the differences in the anthropometdc data were measured usingoropharyngeal measurements betweensnorers and non-snorersand thus be usedthe same technique as in Phase I. Themeasurementswere done by a singlejuniorto delineate the two population; 3) to ENT resident who was blinded as to thedetermine the value of age ,height and presence of snoring.These data comparedweight in predicting oropharyngeal to numerical values derived in the firstmeasurement 4) to provide numerical phase of the study and subjects werevalues derived from linear regression subsequentlyclassified as snorers or nonequationsfor the various oropharyngeal snorers.Parametersthat correctlypredictedmeasurementsto predict snoring and the snorers were considered probable sites ofprobable sites of obstruction and 5) to obstruction.determine the specificity, sensitivity,positiveand negative predictive values ofStatistical analysis:To validate thethe derived numerical values in predicting derived linear regression formulae andsnoringandthe probablesitesof obstruction numerical values, the following wereother than snoring (excessive daytime determined:sleepiness, personality changes, etc.). Sensitivity- percentageof correctlyTherefore, sleep studieswere not done as predictedsnorersas a proportionof all truepart of evaluation. Data regarding height, snorerscomputedas:actualweight and ideal body weight (IBW),together with age and sex were likewiseobtained. Due to the differences in thetrl_e_true positive+false negative('rP+Dositiy_FN)or (TP)measurementsand proportionsof the male Specificity- percentage of correctlyand female anatomy, data were analyzed predicted non-snorers as a proportion allseparatelyfor bothsexes,non-snorerscomputedas:Statistical analysis: Preliminary true neaative or (TN)correlation of oropharyngealmeasurements truenegative+false posttive (TN+FP)with snoring was carried out usingSpearman-Rank correlation test. All Positive predictive value - percentage ofparameters with significantcorrelationat a correctlypredictedsnorers as proportionoftwo-tailed measure were then subjected to all predictedsnorerscomputedas:two-group comparative studies usingStudent'sunpairedt-testwith a p value of < truetrue positive+falsepositivepositiveor(TP+FP)0,05 considered significant, All identifiedparameterswhichcan delineatethe snorers Negative predictive value- percentage offrom the non-snorerswere then subjectedto correctly predicted non-snorers as a

0ro0o o,a,0red,ore0 ,on non snorers Ia,ki,n.y .... jontcomputed as: diabetes/_ndocrine disordersbloodpressureand otherstrue neaative or { T N )true negative+false negative (TN+ FN)MATERIALS AND METHODSAll patients had a standardThis study consisted of two phases, otolaryngologic examination which includedPhase i involved identification of examination of the nose, pharynx andparameters that correlate with snoring and larynx with a mirror. The tongue wasderivation of linear regression formulae to depressed using a metal tongue depressorpredict snoring. Phase II involved validation to allow better visualization. Particularof the formulae, attention was focused on the oropharyngealstructures which were measured inPhase I. Identification of millimeters (ram) using an uncalibratedparameters and derivation of linear stainless steel two*prong caliper. Theregression formulae. All subjects ages 20 distance obtained was then calibratedand above who consulted at the out-patient against a Vernier caliper (Figure 2). Thedepartment of the Division of following anthropometric data were obtainedOtorhinolaryngology of the author's (Figure 3): 1) distance from junction of hardinstitution from March to September 1995 and soft palate to root of uvula (SP), 2)were screened as to the presence of snoring length of the uvula (UI), 3) width of theduring sleep. Those who went to the OPD uvula (Uw), 4) distance between the anteriorby themselves or slept alone were not pillars (AP), 5) distance between theincluded. A data .sheet (Figure1) was posterior pillars (PP), and 6) distance fromaccomplished by both the patient and uvula to posterior pharyngeal wall (UP). Allhis/her companion (bed partner or measurements were done by a single seniorroommate) to confirm the presence of ENT resident. In the snorer group, none ofsnoring. Subjects were excluded if they had the patients had symptoms of OSAany of the following: Figure 2. Instruments used for Measuring1, nasal, nasopharyngeal and Oropharyngeal $trutureshypopharyngeal problems -- "alcohol, sleeping pills and otherCNS depressants2. 3. history neurological of recent andintake neuro-muscular of drugs, disorders4. endocrine disorders-goiters _'i ................;5. obvious facial abnormality like micrognathia, " _'- - " '"retrognathiaIFigure 1, Data Sheet (Snorers) Figure 3. Oropharyngeal AnthropometrySubject# Name: age_ Sex ' " ....._ __ _-, ._Address:Phone No.Occu pation: Weig ht(ibs) .... _:... ,.-..._-_;:Re,.tionC°mpanien'sdoes same snorin9 roomn.melto patient; disturb you/someone? height cm __._ • " __ -_:;' _, ,._ ;.::_:"_,::_ _,%_other room __ _'_J'_'_:'_"; _.i-_.":_does othershe/she snoreevery night? "_ ,.::_,_;_ :_-..4 _>_=,_position of patient when snoring__ :_#:;'__'_ " ?:% . "i i _ .:i_-:_!:_h .'.__&.::A'_on his/her back t ( ; --', -'_,._l.~_-__on his/herstomach side.............. _ ._...'' I :""_,__while sittinghave you been awakened by his/her snoring? yesno-_._::¢;_'_i:

Figure 3.1 Anthropometric MeasurementsRESULTSA total of 155 patients wereincluded in the first phase of the study, ofwhich 56 (36.13%) were ascertained to besnorers by their companions. The patient'sdemographic features are shown in Table 1(see Appendix) of which 7.7% of males and5.9% of females were found to snore at theage of 30 years. These proportionsincreased dramatically to 41% of males and41.2% of females who snore at 60 years ofage (Table 2). Approximately 57% ofsnorers were more than 15% heavier thanUvula their ideal body weight (Table 3), of which14% were morbidly obese (i.e. actual weightabout twice the ideal body weight).Table 1. Demographic Features of Patient PopulationFeatures Snorer Nonsnorer..::_. Range 20-67 22-60Male Fernaie Male FemaleAge 35.48 "- 34.70+13.62 35"09(years) 12.08 12.08 +x+SO 20-68 14 1720- t5Height 165,92 156.17+ 167.41+7,58"- 159.3(cm)x+SD+6.01 5.45148-1638+8.17Range 147-175 147-165Soft Palate 147-180Weight 156.67+ 132+ 139.25+21.34 117.7(Ibs) 32.53 25.43 7+x+SD 81-200 18.78Range 61-220 98-18581-170Table 2, Age Distributionof SubjectsAge Snorer Non SnorerGroupsMel.e. . Female Male, Female20-29 3(7.7%) 1(5. 20(36.4%) 12(27.36)9%)30-39 4(10 2(11. 14(2.5,56) 10(22.19_)2%) 8%)40-49 10(25 3(17. 8(14.56) 7(15.96)6%) e%LAnterior Pillars 50-59,.16(41%) 7(41. 2%) 8'(14.5%) 9(20.40_)"=60-69 6(15. 4(23. 5(g,1%) 5(11.46)4%) 5%,,.)....70'.above 0 0 O 1{2.361 ,Total 39 17 55 44Table 3. Weight DJstribution of SubjectsSoft Palate to Posterior Pharyngeal WallWeight Snorer Non(%oNBW)Snorer>10% less than IBW 3(5.461 12(12 1%)+106 of !BW.. 14(.2,,5.0.%.[. 67(67 7%)10-156 mo..rethan IBW 7(12.56) 5{5%)16-206 .morethan IBW 8{14.36) 8(,8,16._>20% more than IBW 2..4*{42.g%) 7**(7.16)Total 56 99*8(14.g8%)were morbidlyobese, i.e. twice the IBW*'1 (1%) was morbidlyobese

3_ .... .Patientand 2D) was not observed in the 45 -Exami .... avigated on hiswheeled chair t..... fromMe left to 'the right of the patient Good functioninglaryngoscopic procedures. ,,_ed ch.ajr on.the chairs help mobilize the physician.46 -This examiner used the wheels of hie chair to propelhimself forward and backward thereby preventing tooTable 12, ObservedFrequencyof Head Position much trunk flexion.Assumed by the Examiners while Doing 51 . Backrest end an'nrest features on the physician's chairall_ed th_ examiner to lean back end rest his arms inIndirectLaryngoscopy between examinations.n=44POSITION ..... number PercentageUpright ..... 18 40.0%Extension 13 29,5%L_t Flex=on 6 13.6%Protrusion =_ 3 6,8% ,.,Rotation .... 1 2.3%"- DISCUSSIONlateral bending 1 L z3_',._. The current standard ENT texts'Extension+let. Bending ... 2.S_ reference to proper posture while doingextension + rotation 1 2.3%- physical examinations are limited toApproximately 41% of head statements regarding avoidanceof stoopingpostures were in the neutral or uprightpostures,occupyinga comfortable position,position.Only slightmovementsof the head and using a patient's chair that can bewere observed in the performance of indirect elevated, preferably a hydraulic chair. Inmedical school, most students are taught tolaryngoscopy,examine ENT patients seated, in the face toTable13.ObservedFrequency of Leg Positions face position, with legs to the side of theAssumedby Examiners while Doing Indirect patient. This position may be socially andLaryngoscopyculturally proper, however, it causes spinen=44LEG POSITION ........... number Percentage- rotation and places the examiner's back at_ntront ........... risk of injury, specially if the rotation isa. open 16 36.4%b.-clo,ed ...... 1 2.3_ combinedwith flexion."_ide'by side 26 ' - 59.0%Interlocked 1 23% Results reveal that 92 out of 138 or66.66% of all back postureswere recordedTable 14. Some Observationson Ergonomically as having some degree of rotationSignificant Practicesand Adaptations of Some Subjects (Subcategory B + D). Back rotation wasto their Working EnvironmentSubj_Cbde..... Commen=/Otise_,etiensnoted tO be the highest in sitting otoscopy01 .spent severel minuteswith the back twistadto the right" procedures at 67.8% and lowest in thewhile writing on the chart and prescribing; ramped w_rkarea and poor placement ofwriting surface standing otoscopy procedures at 45%.-similar observations made on other subj.e.cts Anterior rhinoscopy and indirect02 "'-patients was twisted/rotated left to right while doing _etescopylaryngoscopy, which were both done from-decreases stress on examiner's back but somehowinconvenienc= the patient the sitting position, yielded 58.7% and03 -examinerls cloud legs posi'doned in between male 61 .4% prevalence of back rotation,patient's legs during examinations; not frequenUyobserved but not unusual in practice respectively,-prevents twisting of lower back and decreases trunkflexion by decreasing patient-examiner distance10 -exemi ..... de a 270 degree rotation ut,lizing his seat It was also observed that a side-byfeatureto shift from the left side to the right side of thepatient during oto_opy side leg position resulted inevitably in-prevented unduet,Mstingoftheback: patient notinconveniencedrotation of the lower back while, for an open11 .... sslng the legs while doing' "the"ex_mination may leg position of examination, only 4 out of 44book graceful if done propedy by lady but this practicehas been recognized as stressful to the hips and is or 9,0% of examinations done weredetrimental for clrculation of the le_]s associated with back rotation.12 -Subject is a shorter examiner who did all of hiso4.oacopies standing up. Does the examiner's heightdictate _e examina_on p ,c_tur,e assumed? Anderson and Nachemson13 -The examiner being very tall and heevyset, removedhis heedhght and held itsothat he could raise his head, separately documented using intradiscald_r_ae his trunk flexion and relieve back andabdominal stress while doing rhinoacopy on a short pressure measurement studies and EMGpebent,studies that rotation and lateral bending of30 .Sitting the patient at an angle from his chair resulted inless rotation for the examiner's back the trunk further increasedthe disc pressure& examiner's thigh were pc=sitJoned almost'side--by side with no trunk rotaflon on the pert of the patient, as well as increased the contralateral-This position resulted in a decrease in the patient- muscle activity, probably to increase theexaminer distance as well as a decre_e in trunkflexion needed to gem a_ess_o the patient, force needed to balance the trunk.40/41 -Both examiners were the only 2 subje¢_ who bentforward more than 20 degs.while performing indirectlaryngoscopy. They utilized similar examination area Rotational and bending movementsset-ups using a fixed light SOurce and _e right edge ofthe writing table adjacent to the left side of the patient, also impart shear and torsional stresses toThe cramped working area probably contributed to thisposture.

the disc whichare less tolerated than tensileAdams (1995) reviewed a series ofand compressive stresses,experiments regarding the effect of postureon the lumbar spine and convincinglyThe emergence of intra-abdominal argued that a slight flexed or flattenedpressure measurementsas an indexof body lumbar posture is better than an erect o,rstress was based initially on the theory that "military" posture since the wedging effectthe trunkactsaspressurized cylinder to help on the disc allows it to resist highersupport longitudinal compression of the compressive forces as well as improvesspine induced by physical activity. These nutrient delivery to an otherwise poorlymeasurements have been repeatedly shown perfused disc. Adams further cited theto increase in forward flexion and rotation, controversial argument that old chairlesscultures who favored sitting or squattingBack flexion greater than 20 positions that flex the lower back have fewerdegrees was observed in 38 out of 138 or back problems but also acknowledge the27.5% of all examinations performed, remote possibility of prolonged low-loaddamage to the disc due to its fexion.The high percentage of Category 2flexion postures observed in otoscopy The third group of common postures(58.3%) compared to 17.4% and 4.5% in observed are the combined postures. Moreanterior rhinoscopy and indirect attention should be directed towardslaryngoscopy respectively, could be partially postures under Categories 2B, 2C and 2D -explained by the fact that more otoscopies postures with more than 20 degrees ofwere done in the standing position with the flexion combined with rotation and/or lateralpatient remaining seated, thereby bending. These postures could benecessitating more flexion from the considered as being the most stressful onexaminer. Another explanation could be the the back.requirement of the procedure to bring theexaminer's head close to the patient's ear, The overall prevalence of theseunlike in rhinoscopy or laryngoscopy where postures was 23 out of 138 or 16.6% for allthe examiner can observe from a distance, procedures done. The highest distribution ofthese postures was again observed in theSpine flexion has again been otoscopy procedure probably because of thedocumented by several authors to be same reasons cited earlier in the discussion.stressful to the back. Nachemson's Percentages of these combined Category 2pioneering work in litradisCal pressure postures were computed at 5 out of 46 ormeasurements provided basis for 10,9% for anterior rhinoscopy and 0% forestablishing the following principles:indirect laryngoscopy.1. the load on L3 in sitting can be as much The combination of forward fle_ionas three times the trunk weight;and rotation placed the spine at risk of injury2. sitting loads are higher than standing during the de-rotation and re-extensionloads;phase, which must be accomplished in a3. increasing forward flexion shows a strict physiological manner. Faulty relinearincrease in intradiscal pressure; extension is a well-documented cause of4. bending forward 20 degrees from pain and, may result in "locking" of theupright sitting increases pressure by articular facets as well as disc.tears. Theseabout 30%.phenomena are more likely to happen to theolder age group who, unlike children, haveIncreasing flexion also causes less flexible spinal components.increased myoelectric muscle activityleading to muscle fatigue. The role of Although the standing postureposterior back muscles in low back pain has results in less spine compression and betterbeen widely discussed. Forward flexion also mobility, the greater angle of forward flexionaggravates disc stress by impairing non- required to examine a seated patient or onecompressiveforces,whose ear level is very low causes theexaminerto bend very low and again, placehis backat risk.

Very slight head movements were a. The back postures of rotation,noted for both indirect laryngoscopy and flexion, lateral bending, uprightanterior rhinoscopy. Perforrning otoscopy, and their combinations were allhowever, required most of the examiners to noted to have been assumed bytwist their necks, sometimes close to the the subjects;limits of motion. Spine compression loads b. The head postures of rotation,have been argued to lead to local regions of flexion, extension, lateralstrain, specially in postures that are close to bending, upright, and theirtheir'limits of motion, combinations were observed tohave been assumed;The preceding arguments have c. Four types of leg positionsmade it clear that increasing degrees of described as side-by-sideflexion, rotation, and lateral bending, and (65%), open-in-front (36.5%),especially combinations of these postures closed-in-front (1.7%), andare either stressful, produce discomfort or interlocked (0.8%) wereare potentially harmful to the spine, observed to have beenAnderson, in 1985, advocated the following assumed by sitting examiners;posturalconsiderations: d. In doing otoscopy, both thestanding (41.6%) and sitting1. Forward flexion should be avoided (58.4%) positions werewhen possible as the trunk moment observed to have beenincreases with forward flexion thereby assumed;increasing muscular activity and disc e. No subject assumed theloading; standing position in doing2. Lateral bending and twisting create not rhinoscopy or laryngoscopy;only high loads but also asymmetric f. The common examiner'sdistribution of forces; postures noted in otoscopy are:3. When sitting, a chair should be providedwith adequate back rest and, where lower back: flexion of more thanappropriate, armrests and 20 degrees with or without other4. Prolonged work in any posture should movements (58.3%)be avoided.head: rotational positions with orTiming of the examinations was without combined extensionundertaken and included in the data and flexion movementscollection to emphasize that even ifperforming these activities only takes a few legs: the side by side legseconds, the cumulative time spent position (57.1%) and the openexamining several patients in the above leg position (42.9%)mentioned postures may make a significantcontribution to the causation of back pain. g. The common examiner'sThis data may also be used as reference for postures noted in anteriorfuture studies that may need to estimate the rhinoscopy are:amount of work involved in doing thesetasks, lower back: 0 to 20 degreesflexion with or without otherSUMMARY AND CONCLUSIONmovements (85.4%)head: upright (37%) andIn summary, this study reveals that: extension (37%)leg: side by side (63%) and1. Junior ENT residents assume a variety open leg position (32%)of lower back, neck and leg posturesduring the course of performing h. The common examiner'sotoscopy, anterior rhinoscopy and postures observed in indirectindirect laryngoscopy; laryngoscopy are:

lower back: 0 to 20 degrees the subject should involve experts in theflexion with or without other fields of orthopedics, rehabilitation medicine,movements (95%)ergonomics and occupational medicine. Noattempt to associate low back pain with poorhead: upright (40.9%) and posture was made in this study Provisionsextension (29.5%)for such associations will be made by theauthors in the future. Also, it would beleg: side by side (59%) and beneficial to include studies on arm positionopen leg positions (36.3%)during the ENT examination2. Some postures assumed by junior ENT A similar study regarding theresidents during the course of their practices of consultants should beexaminations are relatively stressful interesting in that there is wider choice ofand/or place the spine at a position of equipment, clinic set-ups and clinic arearisk to injury,available to th&m. The examination posturesmay be greatly affected by the abovea. Forward flexion of more than 20 mentioned factors.degrees combined with othermovements were deemed as theAn interesting concept encounteredmost stressful and potentially in one of the reviewed literature is that of aharmful back postures observed,semi-standing work posture which could beb. Head Rotation Position combined integrated into plans for development of awith extension postures were new generation ENT clinic or chair.deemed the most stressful positionsobserved.The use of rigid telescopes in ENTc. The most stressful and potentially out patient practice has brought a newharmful of all head and lower back dimension to what was previously known aspostures observed were most the traditional ENT examination. Since thisprevalent in otoscopy, new development alters the spaced. The side-by-side leg position of the requirements and postural adaption of theexaminer invariably resulted in lower examiner, studies evaluating the use ofback rotation, a position which adds these instruments may lead to a new chairstress to the spine,or clinic design that is engineered for ande_ Back rotation was noted in only 4 of unique to the specialty of44 of 9% of procedures done in the Otorhinolaryngology.open leg position.APPENDIX ASUBJECT QUESTIONNAIRERECOMMENDATIONSName(optional) Age/Sex DateInstitution Year level HandednessIn light of these observations that weight_ HeightSomatype: []ectomorph []mesomorph []endomerphthe stressful postures assumed duringexamination be significantly modified at will 1. Do you[ have ] yes a(pls. diag.... specify) d organicback tend,ben?by examiners, it is, therefore, recommended[] nothat ENT residents,in particular, and all ENT 2. Coyoureegu[arlyany section of experiencethe osteoarthromuscular feelings offabgue and/orpainaffectingligamentouspractitioners, in general, be made aware ofapparatus?[ ] yessound biomechanical and ergonomic [] no3, HOWoften do you experiencethispain?principles. 4, if yes to #2, how long have you had this recurrentpain?Postures are governed by a5. If yes to #2, pleasespecify Iocationls.multitude of factors, personal preferences [] Back []Arm/NeckLegbeing only one of them. The logistics []upper ba_k []neck [lh_p/upper_eg[]lower backNo.[ ] shoulder/upper [ ]knee/lowerarmlegneeded to objectively and comprehensively []elbow/forearm []ankle/footevaluate postures and ergonomic 6. Ifyes, doyou haveto take reedcat onsor consultanotherdoctorsoconsiderations are beyond the technical thatthepainwillgoaway?[ ] yescapabilities of the authors. Plans for [] noprospective, randomized future studies on

APPENDIX B Leg positionCHECKLIST a. to the side [ ] [ lb open [] []No.c. othersInstitutionDateE. Total time elapsed (sacs.)I AVAILABLE EQUIPMENTA. Patient's Chair F.Remarks;1, fixed stool/chair []2. screw type stool [ ]3. ENT chair [ ]4. Barber's chair []5, Dental chair []O. Others (specify) [] BIBLIOGRAPHYB. Physician's Chair 1 2 3 4I, Fixedheight [] [] [] [] 1. Adams MA, The Effect of Posture on theAdjustable height [] [) [] [] Lumbar Spine. Journal of Bone and Jointa. hydraulic [] [] [] []b, screwtype [] [] [] [: Surgery. 67B: 4, 625-629. 19852. Anderson GBJ. Posture and Compressive2, Stationary [] [] [] []Withf_nctioning [] [] [1 [] spine loading: Intradiscal pressures, trunkwh.el_ myoelectric" activities, intra-abdominal and3.Withcushion [] [] [] (] biochemical analysis. Ergonomics, 28: 1,91-Without cushion [] [] [] [] 93, 1985.4. W,thlumbarsupport [] [] [] [] 3. Anderson GBJ et al. QuantitativeWithoutlumbar [] [] [] [] Electromyographic Studies of Back Muscles_ppo_ Activity related to Posture and Loading,5.Witharmrest Withoutarrn[est [] [J [1 [) [1 [] ;] []Orthopedics Clinics of North America.,8:1,85-96. January 1977.6.Rotatingseat [] [] [; L; 4. Cartas O. Quantification of Trunk MuscularFixedseat [j [] [] [3Performance in Standing, Semistanding andOperation descnpt.... sitting postures in Healthy Men. spine18:5603-609. 1993.n.WORKINGAREA A. Air-conditioning [.] yes [] no5, Cassisi J, Trunk strength and LumbarParaspinal muscle activity during IsometricB.Floorplan(illustration anrJmeasurementS) Exercise in chronic low back pain patientsand controls. Spine 18:2. 245-251, 1993.APPENDIX CTALLYSHEET 6. Colombini D et el. Posture Analysis,Ergonomics 28:1.275-284, 1985..... 7. Davis PR. Intratrunctal pressurePabentnumber mechanisms. Ergonomics 28:1293-298,1 2 1985,A. Patient profile1.sex 8. Engels JA et al. Physical work load and itsfemale [) [ ] [] [ ]Assessment among the Nursing Staff in2.Status Nursing Homes. Journal of Occupationaladult(age)[]__ [1__, Medicine. 36:3, 338-345. March 1994.pediatric (age) [ ] -- [ ]....9. Frymoyer JW, Risk Factors in Low Back_. patie.tp_i_on 1. seated [ ] [ 1Pain: An Epidemiologic survey. J Bone Joint2. standing [] [) Surg. 65A:2 213-218. February 1983.&others(specify) [] [] 10. Gagnon met al. Lumbosacral Loads andSelected muscle activity while turningC.Equipment Used Patients in bed. Ergonomics 30:7. 1013-t, patient ohair 1032, 1987.2.physician's3. light source chair 11. Harber Pet al. Occupational low back pain inheadmirror [] [] Hospital Nurses. J Occup Med, 27:7, 518-head,_ht [J ;] 524,July 1985.D.Examiner 12. Harber P et al. Importance of Non-Patient12. si_ng stanaing [] [ j r] []Transfer Activities in Nursing-related Back&others (specify) Pain: Questionnaire Survey and Observal.owback position tional Study and Implications. J Occup Med._._prig_t ;] [l 29:12. 967-974 1987.b.flexion(degree_) []"-- [)-- 13, Hettinger Th. Occupational Hazardsc, extension [] []d.lateralbending [] [] Associated with Disease of the Skeletale.rOt_t_o. [; [l System. Ergonomics. 28:1. 69-76. 1985.Headpos,_on 14. Howorth MB. Management of Problems ofa,upright b. flexion (degrees} [[] ] [[] ]the Lumbosacral Spine. J Bone Joint Surg.c._eneio. [] [] 45A: 7. 1487-1508, October 1963.d. lateral bending [] [ ]e, rotation [] [ ]

15, Kraemer J, Dynamic Characteristics of theVertebral column. Effect of Prolongedloading Ergonomics. 28:1.95-98. 1985,16. Koreska Jet al. Biomechanics of the LumbarSpine and its Clinical Significance. OrthopClin N Am. 8:1, 121-133. January 1977,17. Nachemson et al. in vivo measurements ofintradiscal pressure. J Bone Joint Surg.46A:5, 1077-1092. July 1964,18. Schimdt W. Dynamic Instrument placementand Operator's and Assistant's Stoolplacement. Dental Clinics of North America,15:1. 1971.19. Weinert A. An evaluation of the ModernDental Lounge chair, Dent Clin N Am. 15:1,1971.20, Adams Get al. Boies Fundamentals ofOtolaryngology. 6 ed WB Saunders Co.,Philadelphia, PA. 1989.21. Cailliet R. Understanding Your Backache. FADavis Co. 1984.22. Cailliet R, Low Back Pain Syndrome.4 ed.FA Davis Co, 1988.23. Cummings CW et al, Otolaryngology-HeadNeck Surgery. 2ed, Mosby-Year Book Inc,,St. Louis MO. 199324.. White A and Panjabi. Clinical Biomechanicsof the Spine. 2 ed. JB Lippincott Co., 1990.25. Kimmel and Walker. Practicing Dentistry:Ergonomic Guidelines for the Future.Quintessence Books. Berlin and Chicago.1972.

"ACRYLIC PROSTHESIS"ITS ROLE IN THE MANAGEMENT OF ACQUIREDEXTERNAL AUDITORY CANAL ATRESIA*EUGENIO TOMAS ALONZO, M.D.**EDMUNDO M. FALCON, M.D.***ABSTRACTThis case report demonstrates the role of customized acrylic prosthesis in themanagement of acquired external auditory canal atresia in a 3 month old female infant. With theprosthesis, the patency of the ear canal after canal plasty was maintained. The hypertrophic scarbecame smaller and the diameter of the canal increased four-fold.Keywords: Acrylic Prosthesis, Acquired External Auditory Canal Atresia, CanalplastyINTRODUCTION auditory canal atresia. The mother claimed,that the child had patent external ear canalsAcquired external auditory canal at birth. At age two months, the child hadatresia is usually secondary to an acute or bilateral ear discharge which was managedchronic inflammation of the skin in the by a pediatrician with antibiotics and dailyexternal auditory canal_ Cremers 1 (1993) aural hygiene. After three days, the motherreported 17 cases operated from January noted bleeding on ear cleaning which1985 to 1990. The treatment advocated spontaneously disappeared. The infection(Beales and Soliman, 1993) was canalplasty was controlled. However both canalswith or without bone widening and became narrowed with formation ofapplication of synthetic stent to keep the ear hypertrophic scars.canal patent during the epithelializationprocess. Physical examination revealedobliterated ear canals due to hypertrophicThe available synthetic prosthesis in scar. The rest of the ENT findings wasthe market is made of silicone block which is unremarkable.biocompatible, readily available and easy tofabricate but is expensive, may be too soft to Initial conservative managementprovide pressure and must be carved in with weekly intralesional injections of 3 mgorder to fit the patient's ear canal. Triamcinolone Acetonide (Kenacort 10mg/ml) for four weeks failed. Surgery wasThe use of silicone stent has varied thus contemplated.results since the prosthesis should becarved to snugly fit the contour of the canal Brain evoked response audiometryand should at all times be fixed properly in performed pre-operatively showed normalplace. In the case of this patient these two results for age (Appendix A.). X-ray of theconditions did not obtain and re-stenosis mastoids, revealed mastoiditis andoccurred. Hence the search for an cholesteatoma, left (Appendix B.).alternative stent, Complete blood count, urinalysis and chestx-ray were normal (Appendix C., D., E.).CASE REPORTA three month old baby girlpresented with bilateral acquired external"Presented, PSO-HNS Surgical Case Report ContestApril 8, 1995, Subic International Hotel, OIongapo City**Resident, Department of Otorhinolaryngology, Rizal Medical Center***Consultant, Department of Otorhinolaryngology, Rizal Medical Center

CHARLOTTE M. CHIONG, M.D.ABSTRACTS EDITORVALUE OF VIDEOSTROBOSCOPICPARAMETERS IN DIFFERENTIATINGTRUE VOCAL FOLD CYSTS FROM POLYPSArticle by * Jack A. Shohet, MD, Mark S.Courcy, MDMargie A. Scott, MD, and Robert H. Ossoff,DMD, MDLaryngoscope 1996; 106:19-26This paper investigated stroboscopic Periodicityparameters that would allow the laryngologist to (1) Regulardifferentiate benign true vocal fold (TVF) cysts (2) Irregularfrom polyps or nodules before surgery and to (3) Consistentcoo_finn this with histologic findings, A chart Mucosal wavereview of adult patients with benign TVF Rightpathology treated surgically by the senior author (1) Great (2) Normal (3) Small (4) Absentfrom November 1990 to May 1993 were Leftreviewed. There were 32 patients who had both (1) Great (2) Normal (3) Small (4)Absentpreoperative videostroboscopic examination and Closurepostoperative histologic examinations. Tile (1) Completeparmneters described by Bless et al (1987) were (2) Incompleteused to describe the stroboscopic findings (Table(3) Inconsistent1.). There were 20 histologically confirmedpolyps in 19 patients and 14 histologically COMMENTARYconfirmed cysts in 13 patients. After acomparison of histologic diagnosis with the Exudative processes in the Reinke'soriginal pathologic report, diagnosis was space can now be differentiated by usingchanged in 11 (34%) of 32 patients_ The fiberoptic laryngoscopy and laryngealsurgeon's postoperative diagnosis differed from stroboscopy. This paper highlights the need :forthe clinicolustologic diagnosis in 25%, of cases a more descriptive terminology for what hasof the videostroboscopic parameters, mucosal been clasically designated as "nodules" andwave was tile most useful in differentiating "polyps". What I found interesting is that thispolyps from cysts. Of 14 patients with TVF confusion in the histologic interpretation of truecysts, 13 had no mucosal wave on the involved vocal fold lesions was noted by Fitz-Hugh,segment while the other one had a diminished Smith and Chiong AT (Laryngoscope 958;wave. Of 20 patients with TVF polyps 16 had a 68:855-75) nearly 40 years ago! This paper reitnormalor increased inucosal wave. None of the erates the need for the laryngologist to shareother stroboscopic parameters such as symmetry, detailed information, perhaps includingamplitude, periodicity and closure showed stroboscopy findings with the pathologist. Astatistically significant difference between tim 2 series o_ stroboscopic examinations in responsegroups, to either voice rest, medical intervention orvoice therapy may provide a basis for aTable l. Stroboscopic findings diagnosis of vocal fold polyps, nodules andSymmetry cysts This preoperative diagnosis will partly(1) Synunettic dictate the surgical plan and subsequent(2) Asylmnetric rehabilitation.AmplitudeRight(l)Great (2) Normal (3) Small (4) ZeroLeft(1) Great (2) Normal (3) Small(4) Zero

A CONTEMPORARY ANALYSIS OF ACUTEMASTOIDITISArticle * Richard E. Gliklich, MD, RolandD. Eavey, MDRalph A. Jannuzzi, MD, and Alfonso E.Camacho R, MD,Arch Otolaryngol Head.Neck Su_ 1996;122:135-9This paper is a retrospective review of myringotomy, hospital stay was 7.0 + 4_1 days,admission and discharge diagnoses of acute and for those who underwent mastoidectomy itmastoiditis at the Massachusetts Eye and Ear was 8.6 + 4.4 days. Clinical variables predictiveInfirmary and the Massachusetts General of patients who would require surgery, includedHospital between 1964 and 1987. They an elevated white blood cell count, proptosis ofidentified 124 patients with acute mastoiditis, the auricle, and fever on admission.Average age was 12.8 years and median age was8.0 years; 58% of patients were boys and 42%were girls. What. is notable in this study is that Table 1. Clinical presentation of 124 patientsolfly 55% of patients had a recent episode of with acute mastoiditisacute otitis media and not all patients presentedwith expected physical findings. Pain, typically ...........................................................................in the postauricular region_ was the most.common clinical symptom (98%). Physical Variable n total Frequency (%)signs included an abnormal-appearing tympanic .....................................................................................inembrane (88%), fever (83%), a narrowed Pare 121 98external auditory canal (80%), and postauricular Abnormaledema (76%) (Table 1). Audiologic testing was tympanicperformed in 44 patients of whom 39 were membrane 109 88shown to have conductive hearing loss. Fever 99 83.Radiography was performed in 112 patients Abnormalrevealing abnormality in 102; computed externaltomography was performed in seven and proved auditory- canal 59 80useful in identifying spread of infection outside Postauricularthe mastoid cavity. All patients were admitted edema 94 76to hospital, and treated with intravenous Postauricularantibiotics; double-agent therapy consisting of erythema 81 65ampicillin or oxacillin in combination with Auricularctfloramphenicol was used in the last 5 years of proptosis 52 42the study, while earlier in the study, 69 patients Otorrhea 32 26received single-agent therapy, usually with Complicationpenicillin.Cultures were performed from either (at presentation) 33 27myringotomy or mastoidectomy specimens in 99 Radiographicpatients and were negative in 33 (24 of these abnormality 102 91patients had been taking oral antibiotics); ofpatients with positive culture results, The conclusion of this paper is thatStreptococcus pneumoniae was the most since clinical manifestations vary, thecommonly isolated organism. Mastoidectomy practitioner must consider acute mastoiditiswas required in 67 patients (54?/0) because of even in the absence of a history of recent acutefailure to respond to medical therapy or because otitis media. Surgery is frequently stillcomplications of infection extended beyond the necessary and acute mastoiditis remains amastoid compartment (33 patients). For potentially serious infection.patients treated medically alone or with

A PROFILE OF OPD EXAMINATION POSTURESOF JUNIOR ENT RESIDENTS IN METRO MANILASOME ERGONOMIC CONSIDERATIONS*RANDY CANAL, M.D.**GIL M. VICENTE, M.D.***RODERICK A. SUAREZ, MD**ABSTRACTThis is a descriptive study conducted in five PBO-HNS accredited ENT training hospitalsin Metro Manila with 24 residents on duty at the out-patient clinics as subjects. This studydescribes the common lumbar, head and leg postures assumed by ENT residents whileperforming the different ENT examinations on patients as well as evaluates the examinationposture according to some currently accepted biomechanical and ergonomic principles.This study describes the variety of lower back and head positions assumed by thesubjects in the course of examining patients. Four leg postures described as side-to-side (1.5%),open in front (36%), closed in front (17%) and interlocked (0.8%) were observed to have beenassumed by sitting examinees. All rhinoscopy and laryngoscopy procedures were done sittingwhile 46% of otoscopies were done while standing. Some lower back (category 2) and headpostures were deemed stressful to the spine and placed it in a position of risk. Forward flexion ofmore than 200degrees combined with other movements (category 2B, 2C, 2D) were deemed themost stressful back postures observed. The most stressful lower back and head posturesobserved were most prevalent in otoscopy. The side-to-side leg position invariably resulted inlower back rotation.In the light of the observation that most of the stressful postures assumed could bemodified by the examiner at will, it is recommended that ENT residents, in particular, and ENTpractitioners, in general, be made aware of sound biomechanical and ergonomic principles inrelation to one's practice.Keywords: Ergonomics, ent examination,postureINTRODUCTIONThe contribution of posture in time. Low back pain is considered to berecurrent and troublesome back problems most common disabling musculoskeletalhas been established by several studies on symptoms and the second most costlythe etiology and epidemiology of back pain. medical problem in modern industrialAlthough current ideas on what "good societies in terms of work absenteeism andposture" constitutes are still rather vague, loss of productivity not to mention therecent developments in posture analysis billions of dollars that go into research andnow allow us to utilize both subjective and treatment'of the problem.objective methods to evaluate postures.Cailliet (1984)in the introduction of his book The ENT surgeon is not exempt"Understand Your Backache" highlights the from working conditions that stress the back.fact that 80% of human beings experience Long hours spent sitting or standing inlow back pain at some time during their life uncomfortable positions in the operating" Presented,PSO-HNSDescriptiveResearchContestOctober27, 1995,HolidayInnHotel,Manila*" Resident,DepartmentofOtorhinoleryngology, JoseR.ReyesMemorialMedicalCenter***Consultant, Department ofOtorhinolaryngology, JoseR. ReyesMemorialMedicalCenter

oom are, more often than not, typical of some currently accepted biomechanical andsurgeries common in ENT practice. In his ergonomic principles.Out-Patient clinic, the ENT specialist isrequired to assume a rather awkward andconfined working position that is unique in REVIEW OF RELATED LITERATUREmedical practice: face to face with a sittingpatient at close range. The introduction ofA 1985 review of literatureregardingnew material adaptions to this requirement posture analysis led Colombini et al to thehav_ been few and slow in coming. The conclusion that proper postural analysiselectric headlight, the hydraulic "barber's should include a description andchair", and now the rigid telescope all serve assessment of posture tolerability. Theto increase the mobility and flexibility of the authors of that review recognized theexaminer. However, the expense involved in difficulty in assessment and standardizationacquiring such equipment often limits its of criteriato evaluate the multifactoral naturewidespread use. of postural determinants and suggestedinstead a combination of analysis methodsThe goal of ergonomics, which can such as 1) psychophysical and subjectivebe more restrictively defined as "adapting methods, 2)electromyography, 3) study ofthe work to man, and man to his work", has discal pressures, and 4)biomechanicallong been recognized and developed in analysis.dental practice that they have books andlecture series on the subject. A review ofThe objective methods of analysisergonomics-related literature (Medline and such as electromyography, intraabdominalbibliographies of journals) revealed pressure determinations, and intradiscalvoluminous studies on industrial workers, pressure studies involve highly specializedoffice workers, dental workers, nurses, and apparatus and cadavedc models whichevery other kind of worker but suprisingiy make such undertakings best left to expertsnone on ENT specialists,of the field. However, data gathered fromsuch studies are available and may beIn the light of the above utilized to support arguments regarding theconsiderations, the authors believe that the biomechanical and ergonomic aspects oftime is at hand for ENT specialists to initiate posture.studies that would eventually lead to betterworking conditions for ENT specialists to Nachemson, who pioneered workinitiate studies that would eventually lead to on in vivo determination of intradiscalbetter working conditions for the ENT pressures, and others have repeatedlyspecialist. By embarking on a study on the suggested that an important task in theprofile of commonly assumed ENT prevention or prophylaxis of low back pain isexamination postures by junior residents at to provide ergonomic and posturalthe OPD setting, the authors of this study recommendations on ways to decrease thehope to make the ENT practitioner aware of load on the lumbar spine.the biomechanical aspects of work andintroduce the "ergonomic mentality' into ENTIn a comprehensive summary of thepractice,current state of knowledge on posture andcompressive spine loading, Anderson, in1985, stressed that posture essentiallyOBJECTIVESdetermines the total compressive load onthe spine as well as the load distribution1. To describe the common lumbar, head within the spine and also argued t'hatand leg postures assumed by residents postural recommendations can be madewhile otoscopy, anterior rhinoscopy, and based on this knowledge.indirect laryngoscopy are performed on OPDpatients; Several methods of postureassessment have been utilized with some2. To evaluate the examination postures success, although, most of them are notaccording to their conformity or violation of easily learned nor readily applicable in nonlaboratorysetting. Engels et al

(1994)investigated the physical workload A preliminary survey of the layamongnurses in a nursing home and out/floor plan of the OPD clinics and theobserved and recorded the working postures available examination equipment were mademaking use of the highly technical OVAKO by the researchers.Working Posture Analyzing System, whichrequired the authors to note down the Subjects were observed whilepositions of the back, arms, legs, and head. examining patients at the OPD and theBack positions were described as either lower back and head postures as well as thestrai_lht, bent, straight and twisted, or bent leg positions were noted, as 2 otoscopies, 2and twisted. Head positions were described laryngoscopies and 2 anterior rhinoscopicas free, bent forward, bent to side, bent examinations were performed on patients.backward and twisted. Some subjects were not able to completethe 6 tasks due to power failure at theirOkada (1970) studied static i_orward institution dudng the observation period.bending postures using estimates of the Subjects were initially not made aware of theangle formed between the vertical and a line nature of the study. Efforts to be asconnecting the left acromion and trochanter inconspicuous as possible were made byto determine the degree of trunk flexion, the researchers during the said observationPelvic rotation was not controlled, which was period. Subjects were informed of the natureprobably why the EMG determinations of the study after being observed peformingobtained were not uniform compared with the maximum tasks of interest and werelatter EMG studies. Nevertheless, the results assisted by a researcher in answering thewere still consistent with increasing questionnaire. Consent for inclusion in themyoelectrical activity as degree of flexion study was secured prior to inclusion of thewas increased,subject's data into the data pool.All observations regarding posturesMATERIALS AND METHODS were made by the main author. Thedetermination of the degree of back flexionFive Philippine Board of was done by estimating the angle formedOtolaryngology-Head & Neck Surgery between a vertical line and a line draw from(PBO-HNS) accredited training hospitals the examiner's trochanter to the acromion.(East Avenue Medical Center, Jose Reyes The actual task in the data gathering wereMemodal Medical Center, Ospital ng divided in the following manner:Maynila, Philippine General Hospital andSto. Tomas University Hospital)were main author- recording of posturesselected for the study on the following co-author-floor plan of working areabases: 1) Board accredited for more than - checklist of available equipmentfive years 2) high volume of OPD patients, - time elapsed3) high number of ENT training residents,and 4)regular whole day OPD hours. The postures were recorded onchecklist for each of the 3 task of interest -The hospitals were randomly sitting and standing postures together withassigned observation dates and all junior the 5 basic power back postures (andresidents (first and second year) assigned at combinations thereof), namely:the OPD during those times were included inthe study. A total of 24 junior residents from 1. uprightthe 5 institutions were included. 2. flexion (including an estimate ofthe degree of flexion)The combined junior resident 3. lateral bendingpopulation in these hospitals account for 4. rotation, and77% (41 out of 53)of the total accredited 5. extension,junior ENT resident population in MetroManila. Junior residents are usually the ones as well as the 5 basic neck postures andassigned to man the OPD whereas the combinations, namely:senior residents are usually assigned to theoperating rooms or wards. 1. upright or free

2. extension upon reintroduction ofthe mirror intothe oral3. lateral bending cavity.4. rotation, and5. flexion. The questionnaire distributed afterthe observation sessions served to provideProtrusion of the head was defined data on the profile of the subjects.and recorded as simultaneous flexion of thelower neck and extension of the upper neck.RESULTSThe backposturesweretabulatedinthe followingmanner:the observed postures A. SUBJECT PROF/LEwere first classifiedas having less than 20degrees of flexion (category 1)or having Table 1, Some included Demographic in the Data stud on the subjectsgreater than 20 degrees flexion (category 2).FREQUENCYThe postures were further sub-classified as S_r_p_e,ize 24male 17having no combined motion (Subcategory _eme,e -- 7A), combined with rotation (Subcategory B, ._.Bmo_,aph_= 28.2+1-2.3combined with lateral bending (subcategory Meenacle{year,) Age range _ ._ 24.36C) and, combined with lateral bending and .... Meenweight(kg,) 65.4+/-14,3Mean height (cm,) 165.0+/- 6,9rotation (subcategory D). , Sematotype ........eotomorph 6 •endomorph 3The position of the legs of the m_aemerph ........ 15seated examiner relative to those of theCompee_t_,v.e_r level 1 13seated patient namely: year level 2 , ,. 11 ....Pain profile .....1. to the sideWith diagnosed organicbeckcondition 32. closed/openinfront3. interlocked,andWithsignificantBack pain r.e.£_uirin£medications ....... tlow5....4. openatthe side. Twenty-foursubjectswere includedin the study, 17 of whom were males and 7The actual time spent doing each were females, Thirteen of the subjects weretask was recorded using a stopwatch, first year residents and 11 were 2nd yearStarting and ending cues for timing were residents,Their ages ranged from 24 to 36standardized as follows:with a mean of 28.2 +/-2.3 years. Meanweight of the group was computed at 65.41. Otoscopy- start timingupon introductionof otoscopekilograms+/- 14.3 kilograms.tip intoexternal auditory meatus in one earData regarding recurrent low backand endtiminguponwithdrawalof otoscope pain was determined by questionnairefrom the other ear(Appendix A).2. Anterior Rhinoscopy Among the subjects included, 3 or- start timing upon introduction of the nasal 12.5% had diagnosed organic backspeculum tip into one nostril and end timing conditions which included scoliosis,upon withdrawal of speculum from the other hyperlordosis and an herniated disc. Fivenostrilsubjects or 20.8% indicated that they hadrecurrent low back pain which compelled3. Indirect Laryngoscopy them to either take medication or consultstart timing upon introduction of the another physician. Table 2 lists the numberlaryngeal mirror into the oral cavity and end of included subjects contributed by each oftiming upon withdrawal of the mirror from the the involved institution. It shows that 50 tooral cavity. In cases where there was more 60% of the study population in eachthan 1 attempt to visualize the larynx, time institution was included in the study.was stopped when the subject temporarilywithdrew the mirror and changed hisexamining position. Timing was resumed

3 3 5 _ l 0 %Table 2, .Breakdown of Subjects pe.r Institution examinations undertaken. Values wereInstitution " # of total # percentage_.uble_;_ juniors computed from 24 subjects who did1 ..... ,.._ 5 8 62._ otoscopy trials, Only 45 values and 442 5 9 55.5_ values were used in the computation for the4 e 12 r_o_ mean time of rhinoscopy and laryngoscopy,G 4 8 50.0%respectively, This was because 2 subjectsB. EQUIPMENT PROFILE were not able to complete the 6 examinationtasks due to power failure in the Out patientTable 3. Features of the Commonly Used Types of departments during the observation period.Examiner's Chair According to Institution Laryngoscopy procedures were shown to..... INST,TUT_ON have taken the longest time to perform withadjustableFeature_.height1 2 .3.. 4 5 a mean performance time of 25.57 seconds.,=,,,,._pe .... × x . and a standard deviation of 16.95 seconds...... .pneuma_c type x ×tun_o_Jwh_ . . :× --× Mean times computed for otoscopy andpaddedeeat .......... _ x rhinoscopy were 15.04 seconds and 14.76lumbarsupport x xarmre_t × seconds respectively.rotatingseat x x x x xCl. OTOSCOPYInstitutions 1,2 and 3 made use ofscrew-type stools as physicians' chair_ Table 5. Observed Frequency of Back PositionsAlthough height adjustment is an option for assumedSitting StandingDoirAilthese types of stools, it is cumbersome and o=2_ N=20 n=4_the authors did not observe any physician "Ba_k>o,_t_o_ . no. _o'" no... %. oowho actually adjusted the height of this _)0 io 20 "stool. The absence of wheels on these degree,,ea. without .... other 6 21.4 i 5.6 7 16.7stools also made some position adjustments move_.,tmore difficultfor the examiner. Institutions4 b._thr.otat_o, c. with lateral 60 "_ 04 0_. 2 10,0 0 _ 2 12.5 4.2and 5 made use of examiner chairs with bend_n_wheels, backrests and pneumatic height d_thboth 5 17.g .__0" "0" 5 10.42) more than 20adjusters. The backrests provided postural _e_,e_onrelief for the examiner in between a._thootothar3 _o7 7 35.0 _0 20_examinations,movement b. with rotation "5 "" 21.4 2 10,0 7 14.6c, with lateral O 0 1 5.0 1 2.0bendingAll examinations requiring co-axial d.withboth 3 10.7 7 35.0 10 20.6lighting made use of head mirrors. Nosubject was observed using electricheadlight.Observed lower back positions ofthe subjects while performing otoscopy areThe most common patient's chair shown in Table 5. Separate columns forused were; 1)fixed height chairs, sitting and standing positions are provided2)pneumatic stools and traditional ENT for since 42% of all otoscopies were done inchairs. Modern hydraulic "barber's" chairs the standing position. Eight subjects did theirwere available in some institutions although 2 observed otoscopies standing while 4they were not used by subjects during the subjects did otoscopy in both sitting andobservation periods,standing p,ositions. Forward flexion of morethan 20 degrees was noted in 60% ofC. DURATION OF EXAMINATIONS standing otoscopies and in 39% of all sittingotoscopies. 58% of all otoscopies were doneTable 4. Time of Doing Otoscopy, Rhinoscopy and with more than 20 degrees forward flexion.......... LaryngoscopyTIME (SECONDS)....... Ok)_;op}' Rhinor.,_opyLanyngosoopy Rotation of the back was observedn=48 n--_6 ........ N=44 in 19 out of 28 of otoscopies done in theMean 15,04 14.76 25,57Median ::= 13.00 11.00 ..... 24.50 sitting position and in 9/20 or 45% in the,Mode 15 6' ,:-:, 15 standing position. Flexion greater than 20Standard 8,78 13.90 16.95_.v_=t_o_degrees combined with other movements(Categories 2B, 2C and 2D)were noted in 8Table 4 shows the mean, median out of 28 or 29% of sitting otoscopies and inand mode for the duration of the 50% of standing otoscopies. Category 2B,

2C and 2D back postureswere assumed in degrees flexion with other movements18 out of 48 or 37.5% of all otoscopiesdone. accountedfor only 10.9%.Table 6_ Observed Frequency of Head Positions Table 9. Observed Frequency of Head PositionsAssumed by Examiners during Otoscopy in the Sitting Assumed by Examiners while Doingand Standir Positions .... Anterior RhinoscopySitting Standing All n=46n=28 n=20 n=28 HEAD POSITION number PeroentaEleHead no % no % no % Extension 17 : : 36,9%Position Upright 17 36.9%rotation 13 48.4 8.L 40.0 22 45,8 Protrusion ....... 6 . 17.4%extension + 0 21.4 2 10.0 9 18,7 Ro,_tion 2 ..... 4,3%rotation Flexion 2 4,3%flexion + 6 21.4 4 20.0 10 20.7rotationextension + 0 0 3 _0" 3 L 6.2 Only 5 head positions wereint. bendingextension_ _ ,_ 3.s 2 _0o : 4.7 observed to have been assumed by theflexion 0 0 1 S.0 _ 2.4 examiners while doing rhinoscopy,the mostprotrusion 1 3,6 0 0 1 2.1common being extension and uprightHead positionswere recorded and positions.Each accountedfor 74% (34 outtabulated in decreasingorder of frequency, of 46)of all head positions.Neck rotationandMost common head posture involved neck flexion was minimal at 4.3% each.rotation which were noted in 89% of all Protrusionaccountedfor 17.4%otoscopiesdone inthe sittingpositionandin70% of all those done in the standing Table10.Assumed ObservedFrequencyofSitting by Examiners while Doing AnteriorLegPositionposition.Pure neck flexion, pure extensionRhinoscopyand lateral bending positionsaccountedfor n=46LEG POSITION number -" i'#ercentagelInfronta, open 15 32.0%Table 7. Observed Frequency of Leg Positions b.Qlosed 1 2,2%on!y 13% of all head postures.Assumed by Examiners While Performing Otoscopy inthe Sitting Positionside byside_U 29" "63,0% "n=28LEG POSITION no. PercentageIn front......4_o_ " C3. INDIRECT LARYNGOSCOPYa, open 12 .....b. closed 0 0_:s.id.e b)_4ide. 16 57,0% Table 11. Observed Frequency of Back PositionAssumed by the Examiners while DoingC2. ANTERIOR RHINOSCOPY IndirectBACK POSITION number j_emeen_Table 8. Observed Frequencies of1)0to20 degreesflexionBack Positions by Examiners while Doing a.withoutothermovement. , 17 38.6%Anterior Rhinoscc b. with rotation 19 43.9%BACK POSITION number Percentage c, with lateral bendin_ 0 , . • 0% .: d, with both 6 13,06%1)O t9 2 (3degrees flexion 2)more tha_ 20 degrees flexion .....a. without other movement 16 34,7%b. with rotation 16 34.7% a, without other movement ..... 2_ , 4.5%c, with lateral bending 0 0% b, with rotation 0 0%d. with both 6 13,05% c. with lateral bending 0 0% : : :2_more than 20 degrees fleXion ,.d..with ,both 0 0%,a. withoutother movement 3 6.5%b.withrotation c. iateral bending 60 10.9% 0%All indirect laryngoscopies wered.withboth 0 0% done in the sitting position using a headmirror and a laryngeal mirror. Only 22All antedor rhinoscopy procedures subjects were able to perform the 2observed were done in the sitting position on laryngoscopies required for observation.seated or carried patients using a head Back flexion of more than 20 degrees wasmirror and a nasal speculum. One subject noted in only 2 out of 44 laryngoscopies or awas not able to perform any rhinoscopy due percentage of only 4.5 (Please refer toto power failure at their institution.Forward subjects 40 & 41 in Table 14).flexion of more than 20 degrees was notedin 8 out of 46 rhinoscopies or in 17.4%. Rotation of the backwas noted in 25Rotation of the back was observed in 27 out of 44 (56.8%) while flexion combinedsubjects or 58.7%. Category 2B, 2C and 2D with other movements (Categories 2B, 2C,postures which combined greater than 20

,.. ,#-.,- -_,. -_...:_-8-r...t . , _. ., _. _ -,,_..:._•_-.., , _._.=_'_.-,_._-._.,;; ;,,_,.-,- ,, . .-,,_'_'":'_";' .,,L_.--_"-- :_'-_ ._!_• Z'_,.,:-".._ -..,">;,-."_" " _':-,_:F_..... ".. =;. ,.... _:?.:_ ............... _-,-,,..+._._ ....... ,,,_.,,_.,:.._,_._;'"'_" "; :"': ;;_.... :!_' " _,- i_E_._'.._ _"-_i !.......;......_;_._2_'_.L_'?_. __i_:zili;_.i_i--. extends from the level of the epiglottis to.:_;_?'_._E..._ _. "_'_;'_"': ,_._;_'.._ .................. :_-.::._-%?:.-:_-_;. i__! ,_i/,,reflex. In this regard, this also may happen . '7: ........ __i_-:_"-_"._._'_!;:

o_opharyngeal pain and gag reflex eithe[ route can be used by the attendingexperienced by this group of subjects, physicianDrooling or salivation is elicited by In summary, this study has showngustatory and mechanical receptors located that the NGT takes longer time to insert andat the oral cavity particularly in the buccal is more discomforting to the subjects. NGTmucosa and posterior portion of the tongue also causes nasal pain, nasal obstruction,that led to the increased salivation in the and nasal discharge. Bothersome effectsOCT suojects. During speech, as a cavity of noted for OCT include more oropharyngealthe vocal tract, the pharynx takes an active pain, speech disturbance, gag reflex, andpart in the generation and filtering sound drooling. Over all, the subjects preferred(_s__e_e._a_._p_p_e.ndix XI!l.)_.............................................. OCT over NGT.,:::_... ...... .f ....,:.. ......................[.-.......... s ..... "I"."/9',. '%_.=__ ...-.- f_,._..:.Adaptedfrom Cummings, OtolaryngologyHead and Neck SurgerySecond, the muscles of thepharyngeal region (including the extrinsicmuscles of the tongue) have both a localCONCLUSIONrole in shaping the pharyngeal cavity and amore general role in positioning the tonguein relation to the interior part of the vocal I, Insertion of OGF is easier compa_ed toNGT insertiontract 2, There are more bothersome eftects ofFinally, most of the efferent and NGTthanOGTafferent nerves that mediate the fine control 3. Majority of the subjects accepted andof the speech maneuvers throughout the preferred OCT over NGTvocal tract pass in the vicinity of thepl_aryngeal region. Thus,the OCT acted asa barrier to these mechanisms thereby RI=COMMENDATIONaltering the speech of the subjects in thisgroup At present, OCT can be considereda viable alternative route of deliveringTl_e limitation of this study was the nutrition or other indications to patientsabsence of long term effect. If the tube where NGT has been used in the past.stayed long the subjects may have a hardtime recalling the previous experience whensecond intervention is done. Fu_thermore, BIBLIOGRAPHYthe patient still experienced the effect of thefirst intervention and it would have taken 1. Does, G. Difficult Nasogastric Tube Insertions.EmergencyMedicineClinics of North America,some time for it to be washed out Although 7:1:177-182,1989.inserting the OCT seemed to be a new 2. Desmond, P Effect of NGT on the Noseandprocedure compare to the NGT, not much Maxillary Sinus.Critical Care Medicine,19:4:509-difficulty was encountered during its3.511,1991.GallowayDC, Grudls J.: InadvertentIntracranialinsertion probably because of the wide, Placementof an NGT through a Basal Skullpractically unobstructed cavity it traverses. Fracture. South Medicine Journal, 72.240-241,1979.Although each procedure has its 4. Graney,D. Anatomyand Physiologyof the Noseown advantages and disadvantages which and Surgery,2rid Oral Cavity. ed., OtolaryngologyHeadand 1:35:627-6391264:1101-11121 Neckalmost parallel each other in occurrence, 2:65:1113-1124,1993.

I,5. Keith Wrenn: The Lowly Nasogastric Tube; StillAppropriateafter all these years. American Journalof EmergencyMedicine,11:1:84-87,1993.6. Lind, LJ, Wallace DH: Submucosal Passageof anNGT Complicating Attempted Intubatlon duringAnesthesia. Anesthesiology,49:145-145, 1978.7. Sunga, A (Chairman, Departmentof Psychiatry,Dr.Jose R. Reyes Memorial Medical Center, PersonalCommunication,1995)8. Vicente G., Batol: NGT-induced Sinusitis; AProspective Cohort Study. Phil. Journal ofOtolaryngology-Headand Neck Surgery, 5:85-89,1991.9. Wake, M: The Journal of Laryngologyand Otology,104:17-19, 1990.

i:O:BTURATOR:I PROSTHESESIIFOR ORAL:::::: i i: i i REHABILITATION OF POSTiI AXILLECTOMY PATIENTS*::::: :: : :..... JOHN CARL M BARON;, I[,,,: .....: ..... ....... ......... :i : R.ONALDOA: REYESI ML.'t*'_" ::::{:::: : : : : RAMONANTONiO B, LOR.A MD**:::: :.....: .... ...... : ,.,(.:SE ANGE LTQ UI HARDiLLL.. , ...... -) MD *_.... [ : ::: :::{ [: i : EMMANL..JEL. L_IBA?"_MD**[ :MARAN(.} B:._GAPARAS, ML,7:*_'*:[:: i:: ............ [ ......... :: i::I :[ [ .... : : :...... .... a ?........ R:AC :i : i: : ...... i:hit%,: =: with sLlrgit:;aiiy defects: aiTd:resultaiTtspeec}_arid{:[::: : wele fittedwith a/cca manufacturedobtt.ratort_ost7esesmace of hare1aiid soft ac.rytii::LSpeec,h and swatbwi__,g were evaluated after obturator appti :',ation. All patients,::::]: : :le.qafdtes,,i ........ --, ',:

_ _ -_,,_,,,_,_,_wa.,_-_-KL,_..,_,,_,,_,_,,t_ _abk,i}_R,_-L,_.I_I _ the ....L .... -b'/¸¸L,(,,, ts_}es_ ......... b% _':i v{. L,} "_,_w_...illt£_a_d : ,,_: ' _/ _ , , disct_arge.. With:: _ict.._as_ " :'_"_:.' ":_,::.,>{.,_c,l _-_,,, ....% ct the maildibular: : : ::::.......[ ::......._.,c_....

A thorough review of the family malignancy, Radicular cysts andhistory was undertaken, A brother of the dentigerous cysts are very common butpatient was said to have developed bony usually present and thus unlikely in thisswelling on the legs. However, this brother case. The first seven entities can be easilywas not located and no documentation was controlled completely with adequate incisiondone. Bone scans on two daughters showed and curettage.early signs of calvarial and base of the skullthickening in one of them. (Family tree in Odontogenic myxomas may giveAppendix 3) After the patient was cleared by rise to similar manifestations as this patientthe hematologist, a debridement operation but has a definite histo-pathologic pictureon the mandible was performed under consisting of a basophilic homogenousgeneral anesthesia. However, massive ground substance and a distinctintraoperative bleeding was encountered "honeycomb" radiologicappearance, both ofand despite blood transfusion, the patient which were not present in the patient.suffered hypovolemic shock, went into Because of the persistence of the swelling,cardio-respiratory arrest and expired after ameloblastoma or a possible malignancyresuscitative measuresfailed, must be ruled out. The histopathologicfindings, however, pointed to a chronicAppendix 3: Family Tree osteomyelitis._-"_ _ Osteomyelitis may be primary ort.._'_.. • ,. .._,;_:..: .......:...:. ,.:._ • i}T:.,. li_.._.:! i i,!_i_:i_ ,:,;=:.... :_:_!i _..::.::._ l:_..:;i ,,._.=,..,_,_ ;.i _!i_i secondary manifestations, but, looking the at possibility the other of clinical an•. :...., _:.,.... _ ",.;;;. ,:_, _-:::::.:::.::__..:_:.,. = ..=.,;.:_. _.........._._:_,_ underlying systemic disorder was brought to::_:_::u. I i L:::.;.:u_ _i..ipi':,_il_ !....,-. mind. With the limping on the right leg, the:::::- :i:_:.: ;_:_: :_I_:: _.i.: t...................... -.::;:__/ I:._:_::di possibility of a fracture, or an underlyingd_:::i_.T.!=i......... :i_"::i _:;_:_?_i i__i bone pathology was considered. There was_ ..'•:_i F::.. '_ ........: ,4._...... , _:. ............ severe anemia and thrombocytopenia,:_........ __ .;_._.=_..: ............ :_:d hinting on a possible underlying disorder in_:_JJ!:|t:_ l_ ._-_.:,. _ii: :,__:_......._:._:_, _ . _,_ the hematopoietic system. Optic atrophy',_...._,.-_:ii_i_i_i!i;iii;:ili, i:.i!iiii /iiiii._::i_.i.:.!iiTi was involved. noted Furthermore, and thus cranial withnerves one suffering may be,_@ _ ,...:_:_:_:_.._::._.,_.:_._ from similar clinical manifestations, this,',:_.:::_:_:_. _¢k;._.;.-:M:_:::_:_ __i','.....':"::__:s_::.-_,.. ....._::::::::..:....-.._=,..,:,,_,:.:;;:.,:.: strongly points to a possible hereditary,.. ....,,, ,_ ._........-'.:..:. ..................;_---_._:_i_i_ :.:..._:_:.:..i I =,:'.-!:!:.!!:!:::.:--.:_ disorder.• I' " _:'__ " _"":_:' _'::":"" '_;_.'_j_{ _:', ............................... _.••._i_ _:iii.i,ii:!.__i:i:!:i:k._..Jf'::_::_:iii_ :d__:" i_:_:;_::__:;:_i __ ,!!iii_i.f_.;._ is there a disease entity, or perhaps,•_i_iii::ii_:.j __"_ ; i;J_i a syndrome that could encompass all these........ _;_iiiR_ill.....;_:..:.::i _ multisystemic clinical manifestation? With...... !. all these cranial, mandibular and femoral.......... ii_ii..i_.i_:.i_i was considered. The presence ofi__ ....._" _:_:_:_ _ i bone generalized, involvement diffuse a primary and bonesymmetric•i:_"i'_'_:.;_:_ :.... hyperopacity in all bones, particularlydisorderat theii_!_ _ i.T;:.i..._:.i :_;: skull base and pelvis led to the diagnosis of,_',_,_,: i._,_._i_..:i!__': i .!_.:_ the rare familial disorder of osteopetrosis.ii_L._.'i.'.i;] ...... ;'; _;:'_ Osteopetrosis, or Alber-Schobergsyndrome, is characterized by extraordinarythickness and density of cortical bones atDISCUSSION the expense of the medullary portion. It iscaused by defective bone resorptionThe patient's progressive, painful possibly related to dysfunctioningswelling and enlargement of the mandible osteoclasts while bone formation is normal.despite repeated curettage and antibiotics There are three forms of the disease: 1)suggests several entities, namely: radicular Infantile malignant 2) Intermediatecysts, dentigerous cyst, adenomatoid autosomal recessive, and 3) adult- onset,odonto-genic tumor, odontogenic fibroma, benign, autosomal dominant form. Onceameloblastoma, osteo-myleitis and this disease is survived beyond infancy, it is

of the benigntype. While the first two forms common cranial nerve affectationpresent with severe hematologic, secondary to nerve impingement at theorthopedic, neurologic and other foramina due to bony overgrowths. Othermanifestations and usually perish at birth or cranial nerve affectations of interest toearly infancy, the benign type may still otolaryngologists but not present in thispresent with similarly severe manifestations patient is facial nerve palsy. Retardationbut at later age. It is important for and hypersplenism may be present inotolaryngologists to be aware of these osteopetrosis, but mainly on the recessivedisorders since the skull base is a site of malignant form.proclivity for the osteopetroses and it ispossible that a pdmadly otolaryngologic While advances in radiographicsymptom may be the first sign of this techniques have facilitated early detectiondisorder,of osteopetrotic patients, management hasso far been only palliative. Treatment hasHaving developed manifestations at been focused mainly on stimulatinga relatively later age, and with indications osteopetrotic activity, improve thethat one child, together with a sister and hematologic profile, and avoidance ofprobably another brother, is affected with fractures_ Prednisone (1-2 mg/ kg/day) hasthe disease, oste(_petrosis in this patient's improved the hematologic function in somecase is most probably of the benign patients but no reduction of the bone massautosomal dominant type. Available data has been achieved. An integral part ofgathered through history and radiographic therapy is a calcium-deficient diet. Highdocumentations affirm the genetic mode of doses of calcitrol and parathormone havetransmission of the disease, which in this been given to stimulate osteoclastic activitycase, is most probably from the father's side but no long term and consistentof the family. Prevalence figures for the improvements have been reported. Lately,autosomal dominant form is unreliable bone marrow transplant, interferon gammabecause many patients are asymptomatic and macrophage stimulating factors havealthough one study in Denmark been given in the belief that these may alterapproximated it to be around 5.5 for every osteoclastic and immune defects by100,000 population. This is definitely an stimulating cellular formation and function.underestimate for reports of large families So far, these treatment regimens, alone orwith many affected individuals may change in combination, ameliorate but not cure thethe estimate considerably. The authors were osteopetrotic condition.not able to come across a localepidemiologic report on this disorder.With the numerous severe clinicalmanifestation of osteopetrosis, earlyOsteomyelitis of the mandible, identification is very important, not becausewhich is usually preceded by carious teeth it can be cured, but to avoid unexpectedand dental extraction, occurs in this disorder complications that might ensue, especially ifbecause of diminished vascularity of the surgical procedures are to be performed.bones and decreased resistance to Being a familial disorder, diagnosis will alsoinfection. Pathologic fractures, the most facilitate evaluation of other members of thecommon initial manifestation, occur family, and, accordingly, advise them of thebecause the bones are brittle despite genetic as well as the clinical implications ofhypercalcification. In a series compiled by this disorder. Otolaryngologists, therefore,Heinkel and Belier, out of 25 adult patients should be aware that osteopetrosis, with itsreported, only 28 percent had any numerous hematologic, orthopedic, andsymptoms other than pathologic fractures, other severe manifestations, may initiallyapproximately 45 percent were completely present with a common otolaryngologicasymptomatic, and none had osteomyelitis, problem.although the mandible was involved radio:graphically in 14 of the patients.SUMMARY AND CONCLUSIONThe other manifestationsseen inthe patient are typical of this disorder. TheIn this paper, mandibular swellingsevere pancytopenia was due to the and osteomyelitis has been demonstratedobliteration of marrow cavity by cortical as an initial manifestation of the rare familialbone overgrowth. Optic atrophy is the most disorder osteopetrosis or Albers- Schoberg

syndrome. The hereditary aspects andimplications of the disease have beendocumented and discussed.BIBLIOGRAPHY1. 1.Bencke, J. E.: Facial NerveDysfunction in Osteopetroosis. 7. Kubo T, et al: Malignant osteopetroslsLaryngoscope103 May 1993. treated with high doses of la-2. 2. Blair, H.C. et. al. : Recent Advances hydroxyvitamin D3 and InterfonTowards Understanding of Osteoclast Gamma. J.Pediatrics123:264, 1993.Physiology. Clin. Orthop., 294: 7- 8. Robins, S, et al(eds): PathologicBasis22,1993. of Disease. 3rd editionW.B. $aunders3. Bollerslev,J., Mosekilde, L: Automosal Co., Philadelphia,PA, 1984.Dominant Osteopetrosis.Clin. Orthop., 9. Shapiro, F: Osteopetrosis: Current294:45-51,294. clinical considerations.Clinical Orthop.4. Callender,G.Jr,,Miyakawa, G .: 294: 34, 1993.Osteopetrosis in an Adult. A.J.R.., 10. Turek, S.L: Osteopetrosis in74:46, 1955. Orthopaedics. J.B. Lippincott Co.,5. Heikel,C.L., Belier,D.D. : Osteopetrosis Philadelphia,PA, 1984.in Adults.A.J.R.., 74:46, 1995. 11. Thwaley, S.E. et al (eds.):6. Key,L.Jr and Ries, W: Osteopetrosis: Comprehensive management of headThe pharmacologic basis of therapy, and neck tumors. W.B. Saunders Co.,Clin. Ortho. 294: 85-89, 1993. Philadelphia, PA 1987.

PATTERNS OF PRESCRIBING INTRANASAL STEROIDSPRAYS: A DRUG UTILIZATION STUDYJose Acuin, Ruzanne Caro and Charles YuINTRODUCTIONChronic rhinitis is one of the most per actuation. Most currently practisingcommon ailments that cut through social physicians who are using these drugsand racial barriers. In a 1985 national probably learned about it from continuingsurvey, 41.5 million Amedcans, representing medical education efforts or from drug20% of the total population, was found to be detailing, its use, therefore, reflects not sosuffering from upper respiratory allergy with much the. physician's previous medicalsubstantial symptoms occurring for an education as his contact with peers, withaverage of 19 weeks per year_1. In 1975, current literature and with representatives ofthe cost of medications and physicians visits the drug industry. Although steroid spraysfor allergic rhinitis was estimated at 500 are being recommended for several nasalmillion U.S. dollars. Filipinos probably suffer disorders familiar to ENT practice, itsas much, considering the hot and dusty acceptance among local otolaryngologistsenvironment prevailing in most time of the have not yet been determined.year. The escalating levels of air pollutiontends to worsen the problem.REVIEW OF LITERATUREIntranasalsteroidspraysare a fairlyrecent additionto the array of drugs for the The comparative efficacies oftreatment of chronic rhinitis. Beclometh- beclomethasoneand budesonidehave beenasone diproprionate was first marketed in determined by two single blind trials bythe 1970s, followed by budesonide, Pipkorn and Rundkrantz (1982) andflunisolide and floucortin butylester in the Samuelson (1983) and by a double blindearly 1980s. These highly active topical trial by Vanzielleghem and Juniper (1987)3.glucocorticoids ushered in a new era of All three showed almost equal efficacy ratesnasal allergy treatment, promising excellent with slightly better control of allergylocal control of symptoms with minimal symptoms with budesonide. Sixty to ninetysystemic effects. The antiinflammatory percent of patients, adults and children alike,action of these drugs is primarily based on have been found to experience completetheir ability to induce the formation of control of nasal symptoms. Although orallipocortin, arelease ofprotein which inhibitsarachidonic acid andthetheantihistamines producedallergic ocular symptomsmore relief ofin comparativeinflammatory mediators derived from it. trials with nasal steroids, the latter were justInhibition of endothelial adherence of as effective in alleviating nasal symptoms_.leukocytes, basophil migration and mast cell The indications for the use of steroid spraysconcentration areothersalutaryeffects 1. are fairly uniform across many studies.These,include seasonal and perenial allergicIn the Philippines, beclomethasone rhinitis, nonallergic rhinitis withoutdipropionate is marketed as Beconase eosinophilia syndrome (NARES), nonallergic(trademark of Glaxo) and comes in freon rhinitis (vasomotor), rhinitis medicamentosa,propelled or aqueous nasal sprays nasal polyps and post-polypectomy cases_,delivering 50 mcgm of the active drug per Transient sneezing, stinging or drying, nasalactuation. A total of 400 mcgm per day, or bleeding, nasal septal perforations andtwo actuations per nostril twice daily, is ulcerations have appeared in the literature.generally recommended2. Budesonide is No case of nasopharyngeal candidiasis ormarketed as Budecort (trademark of Astra) atrophic changes have so far been reported.in a freon propelled nasal spray also Compliance has not been problematic and,delivering 50 mcgm of the active ingredient

with hi_lhefficacy rates, has been estimatedat 85%_. Sub-study 2.No local study has yet been made The outpatient records of twodetermining how physicians prescribe nasal otolaryngologists and one pulmonologiststeroid sprays and how patients utilized the from one peri-urban tertiary teachingdrug. This study aims to determine how hospital (De La Salle University Medicalphysicians prescribe intranasal steroid Center in Dasmarifias, Cavite) weresprays in terms of therapeutic indications, reviewed. The number of prescriptions ofdosaging, duration and combination with either beclomethasone or budesonide over aother anti-allergy medications. Compared one year period (1992) were obtained,with allergologists, otolaryngologists are a combined for each type of specialist,bigger group of specialists who treat more compared for possible differences inpatients with allergic rhinitis, who are more prescribing indications and then pooledlikely to be consulted first for nasal problems together to estimate the total number ofand who are frequently targetted by drug units prescribed over the one year pedod.detailing activities. The first part of the The population size of the catchment areastudy, therefore, will focus on was then obtained and used in theotolaryngologists prescribing practices in a calculation of the DDD for Dasmarinas.tertiary hospital setting. The second part ofthe study will review prescriptions made byThe sample size had a 95% chancetwo otolaryngologists and one of detecting a 60% prevalence of a specificpulmonologist's prescriptions. Qualitative indication for prescribing nasal steroiddata obtained from these two substudies will sprays.be utilized in building assumptions andinferences that will enable the calculation of Sub-study 3.the defined daily dose (DDD) per 1000inhabitants per day in the third and final partDefined daily doses were calculatedof the study,from:a) total annual number of units ofbeclomethasone and budesonide soldSUBJECTS AND METHODS from the sales data reported by IMS,December 1992Sub-study 1. b) sales records from a single Mercurybranch in GreenhUls,San Juan, MetroFifty physicians constituting the Manilaarea in San Juan.entire otolaryngologystaffs of two tertiarygeneral hospitals in Metro Manila, thePhilippine General Hospital and East RESULTSAvenue Medical Center, were consecutivelyentered into the study and given Sub-study 1.questionnaires on nasal steroid spray use.There were 9 consultants and 41 residents Among the 33 respondents, 52%in the study population. With a responserate of 100% among the consultants andprescribed budesonide, 27%beclomethasone in either thepreferfreon-60% (24 out of 41) among residents, a total propelled or the aqueous solution form andof 33 questionnaireswere evaluated. Mean 21% use either drug interchargeably. Theage was 28 years among residents and 41 most common indication for nasal steroidsyears among consultants, was allergic rhinitis. The other indicationsmentioned by the respondents closelyThe sample size has an 80% matched those previously mentioned andchance of detecting a prescribing practicewith a prevalence rate of 60%.reflect the current general consensus amongotolaryngologists regarding the versatility ofnasal steroids in treating many types ofchronic rhinitis.

an acute attack of sinusitis when steroidsTable 1, Indications Cited by 33 Respondents for Use are used.of Intranasal SteroidsTable 3. Average Number of Weekly PrescriptionsIndications No.of respondents Of Nasal SteroidsAllergicrhlnit_ 28Vasomotor rhinitts 11 No. ot prescriptionhveek No. of responden_Nasal polyps 18 0- 1 6Sinusitis 0 1 - 2 8Others (poet-polypectorny) 8 2 - 3 43-4 1Most respondents (85%) gave 4-5 >5 o1steroid sprays at the correct adult dosage of _1o No answer 10 32 puffs into each nostril twice daily. Those To=, 3_who were giving it at lower doses claimedthey were tapering the drug and were wary Sixty percent of respondentsof rebound congestion. In children, the averaged 0 to 2 prescriptions per week.correct pediatric dose, 1 puff per nostril Considering that patients with allergic rhinitisBID5, was being given although for shorter constitute about 30 - 40-% of outpatientperiods than in adults. Fifty-four percent of consultations, the underprescribing mightrespondents did not give it at all to children, indicate that intranasal steroid sprays wereThis reflects the general wariness with which being reserved for only the most severe andphysicians administer steroids to children intractable cases as well as for post-surgeryeven though long-term use of budesonide patients who are at risk for developingrecurrent nasal po!yposis. The prohibitivehas been shown not to exert any systemic price of one container may also be at workeffect significant enough to suppress thepituitary-adrenal axis 6. Table 2 further here, with physicians preferring to start withshown that steroid sprays were being given the cheaper antihistamines and reservingadults at periods no shorter than one month, the drug only for those who could afford to itAgain this was in consonance with the over a Iong term basis.general recommendation to use steroid Sub-study 2.sprays for prolonged periods andprophylacatically in as much as itstherapeutic effect lags by at least one week A total of seventy-seven patients outafter initiation 7. of 9.750 consultations were prescribed witheither beclomethasone or budesonide byTable 2. Duration of Treatment with Nasal Steroids three specialists in Dasmadhas, Cavite in1992. There were 29 males (38%) and 48Ouratlon of Treatment No. of Respondent_ females (62%). The mean age was 29Adult Pediatric years. Allergic symptoms were present in_nde, n_t- _ _ 90% of patients and findings of pale1-2 weeks 4 43w_ks o 0 edematous turbinates with clear watery1month 1_ 4 discharge were obtained in 86% The drug2 months 6 23ment,, 2 0 was prescribed for the shrinkage of polypsOepends on indication 2 1No answer 3 _ or polypoid mucosa in 19.4% of patients andDoes°otpr_¢ribe 0 _ for the control of sinusitis in an additionalTot,J _3 3_ 27%. Fifty-one percent have been treatedwith at least a class of antihistamine andNinety percent of respondents 31% with at least one course of antibioticscombined steroid sprays with oral prior to iniatiation of nasal steroid therapy.medications. Antihistamine-decogestant Twenty three of 67 patients received at leastcombinations were the most popular, one course of antibiotics prior to steroidfollowed by antibiotics. This reflects therapy. Steroid sprays were co-prescribedadherence to the recommendation to initially with either antihistamines steroids orcombine the drug with oral antiallergy antibiotics in 48. Ten percent was given oralmedications because of its delayed onset of steroids during the first week of nasal steroidaction. The coupling of antibiotics with therapy.steroid sprays despite a diagnosis of allergicrhinitis may be due to the fear of provoking

A total of 100 unitswere prescribed 1990 and would have been theoretically.overthe one year periodfor a mean duration "exposed" to nasal steroid prescriptions.of onemonthper unitper patient.Althoughthere are other indicationsfor theuse of nasal steroids, sub-studies1 and 2Table 4. Prescribed Duration of Nasal Steroid showed that allergic rhinitis was the mainTreatment in77Patients indication used by otolaryngologists andDuration1 m_'hNumber63ofPatients sincethere is no reasonwhy otherspecialist2mat,, _ would not prescribe likewise, it can be3m=_m 4 mont_ls 2assumed that most physicians would5_,,=_m 1 reserve the drug only for allergic rhinitisTotal 77 cases.Thirty-eightout of the 77 patientsHowever it must be consideredthat(51%) reported for at least follow-up allergicrhinitissymptomswould have to beevaluation. Of these, 63% reported relief rathersevere before promptingconsultation.from most allergic symptoms, 26% were This low consultationrate was supportedbyunchangedand 11% gotworse,the lowfollow-uprate, 50%, amongpatientsin sub-study 2. Further, the rate ofNasal steroid prescriptions are compliance to the advice to buy anseldomsecuredby dispensingdrugstoresin expensive drug (such as either brand ofthis country and thus determining the steroidspray) that must be used daily overnumberof prescriptionsmade over a period at least one month and patients whoseof time would be impossibe at present, symptoms may wax and waneHowever, each unit of steroid spray sold independentlyof the drug, would probablymay be assumedto equal one prescription be low. Personal communicationswithbecause the drug is expensive. Hence, Astra, Phil. product managers (9)patients could probably afford to buy only corroboratedthis low compliancerate whichone unit per prescription and only after they peggedat 20% basedon discrepanciesascertainingfrom a medicalconsultatonthat betweenphysiciansprescriptionsand actualthe medicationwould be efficacious.Sub- productsales. An intermediatecompliancestudy 2 showed that physicians were rate of 50% was adopted for this substudyprescribing one unit at a time and re- since personal experience with patients inassessingthe need for continuoustreatment this area confirma higherthan the nationalevery month.Althoughprescriptionsmay be compliancerate.used more than once, the cost of the drugwouldtend to force patientsto see the cost-The defined daily dose (DDD) foreffectiveness of consulting again before every 1000 inhabitantsof Dasmarinas wasbuyinga subsequentunit.calculatedasfollows:The national prevalence of allergicnumber of prescriptions(n) = totalsymptomsin the Philippineswas assumed unitsprescribedin 1992 = 100to be 15%, that is, similar to the reported average number of doses perprevalence figures of both seasonal and prescription(D) = 200non-seasonalallergic rhinitisin the Unitedmass of each dose (M) = 50 mcgmStates which ranges from 10% to 20% usingeither brand(11,12). The similarity of the prevalence populationsize (P) = 358,500 x O15ratesof the two countrieswas basedon the - (358,500 x 0.50) = 26,888observations that although most forms oftime period('1")= 365 daysallergicrhinitisamongFilipinosare perennial(thus tending to inflate the U.S. rate), the Table 5.Annual Salem ofBud_oni¢le andBeolornetha_on Na_lSpraytabsence of seasonal allergies among Budesonide Beclernethasone To_l50 mcgm/ 50rncgm/Filipinos would tend to pull the actual 200dose= 200dosesprevalence rate beck to a region still near Annualsal_ 35.200 21,500 56.700the U.S. rate. Therefore, in Dasmadnas, unit. .n,_Regional distributionabout 15% of 358,500 or 53,775 inhabitants iettoManila 51.41 53.14would have had some allergic symptoms in Luzon Vimmyas _53 18.54 2o.ll 1e. 55

Mindsnao 12.53 10,21Consuming Patients 97,000 30,000 127,000Ps,o=nt otp_, Population of San Juan = 127,000w/allergic rhinitis 42,6% no data(sou,_,: IMSD_.92)Population at risk for steroid spray exposure= 127,000 x .15 = 19,050DDD = 200 mcgm Therefore, DDD/1000 inhabitants/day =DDD/1000 inhabitants/day = 196 x 200 x 200 mcgm x 1000100 x 200 x 200 x1000 = 2.04 19,050x365x200mcgm= 5.626,888 x 365 x 200 mcgmSub-study 3.DISCUSSIONGlaxo Philippines racked up anational aggregate of 21,500 units of Drug utilization studies are usuallybeclomethasone (Beconase freon-propelled plagued by inadequate databases andand aqueous forms) sold from January to difficulties in linking quantitative data onDecember, 1992. Astra Philippines scored a drug use with actual drug utilization. Thenational sales figure of 35,200 units of defined daily dose (DDD) per 1000budesonide within the same period 8. Total inhabitants, although a generally acceptedsales of nasal steroid spray units was measure of the proportion of the populationtherefore, 56,700. exposed to treatment with a particular drug,is fraught with methodologic limitations thatBased on the 1990 census, the total threaten its applicability to diverse clinicalpopulation of the Philippines was taken to be settings in which the drug in question may60,684,900 10. The rate of compliance to be really used. In the Philippines, the lack ofthe advice to take the drug continuously was local reliable databases, the nonsetat 90% for this substudy based on the observance of the dispensing policies setthe number of units sold and not the number forth by the Pharmacy and the Genericsof units prescribed. This meant that once the Acts and the free-for-all system of healthpatients purchase the drug they will probably care delivery make pharmacoepidemiologicuse it as prescribed. The national defined studies doubly difficult.daily dose was, therefore, calculated asfollows: This study proposes that the bestmeans to forge ahead and surmount somenumber of prescriptions (N) = total units of these daunting problems lies onsold in 1992 = 56,700 maximizing whatever databases areaverage number of doses per available by "triangulating" them withprescriptions (D) = 200 qualitative studies. Thus, although thismass of each dose (M) = 50 mcgm study used aggregated data on sales ofusing either brand drugs, the limitations that threaten itspopulation size (P) = 60.68 million x .15 = 9 internal and external validity of quantitativemillion less 1 million for non-compliance = 8 data may be compensated for by themillion prescriber-based cross-sectional descriptivetime period (T) = 365 days surveys on drug utilization. In this study, theDDD = 200 mcgm choice of drug for investigation --- intranasalDDD/1000 inhabitants/day = steroid sprays--- is particularly auspicious.56,70.00 x 200 x 200 mcgm x 1000 The sameness of dosage per actuation for8 million x 365 x 200 mcgm both brands, the definite indications for their= 39 use, the limited tendency for over-thecounterdispensing because of unfamiliaritySales records from the Mercury to most patients and the limited number ofDrugstore branch in Greenhills, San Juan specialist who are comfortable in prescribingshowed that 96 units of Beconase and 100 them --- all of these factors bolster theunits of Budecort were dispensed from validity of the assumptions made inMarch, 1992 to March, 1993 13. The calculations of the DDD per 1000population at risk was calculated as follows: inhabitants.

Whet remains to be done is for sprays more cost-effective than before.qualitative studies to substantiates these Complianceratesmay alsodiffer from drugfacilitatingassumptionsand in this regard, to drugsincethe mostrecentform of streoidboth descriptivesub-studies,done in two spray is even more expensivethan the onessettingsand using different data collection used in this study. Finally, variations inmethods,succeeded,regionaldistributionmay be effacedby moreefficientmarketing.The differences observed in thecalculatedDDD per 1000 inhabitantsof thenational,Dasmarinasandthe San Juan dataCONCLUSIONS-- 3.8, 2.0 and 5.6, respectively--- areprobablydue to the non-uniformavailability This study has determined theof the drugsthroughoutthe archipelagoand appropriatenessand extent of usage ofthe varyingcompliancerates. San Juan had intranasalsteroidsprays for allergicrhinltis.the highest DDD because of the The two descriptive sub-studies ofsimultaneous presence of the kinds of otolaryngologists in tertiary hospitals inphysiciansand patients who will and can Manila and DasmariSas, Cavite shows thatpatronizethesedrugsin Metro Manila. This intranasalsteroidspraysare currently beingstatement is supported by the regional used as treatment for patientswith allerQicdistributionof salesshowninTable 5.rhinitisand othertypes of medicallycurablewith allergicrhinitidesafter or concomitantlyCompared with other DDD values with antihistamines or antibiotic therapy.previouslyencountered,those calculatedin Otolaryngologistsincludedin the study hadthis study appear comparable and may a definite consensus on the indications,probablyvalidate the decisionto limit the dosaging and duration of their use. Thepopulation in the denominator to the calculatednationaland municipalDDD's persegmentwhichis really at risk. This may be 1000 inhabitantsare differentand reflectthemethodologically questionable but in the unequal distributionand availabilityof theface of drugthat is not as uniformlyavailable drug.nor as widely accepted by either patient orphysician as common antibiotics oranalgesis the choice of delimiting ACKNOWLEDGMENTassumptionsseem inevitable.The authorswish to thank the helpof Mr. Louie Wel, productmanager of Astra,RECOMMENDATIONS Philippines, Mr. Timoteo Cruz and VicValenzuela of Astra, Phil. and Glaxo Phil.,Several assumptions used in this respectively, and Mr. Jess Ustaris, seniorstudy may not be applicablein the short manager of Mercury Drugstore,term because of the entry of one more Shoppesville branch, Greenhill, San Juansteroid nasal spraywithinthe past year and M.M. for their invaluablehelpin securingthethe aggressive marketing efforts of drug salesof Budecortnd Buconase.companies. This tends to increase thepopulation of prescribingphysiciansandhence the size of the survey sample whichREFERENCESwill be drawn from them. The prevalenceofirrationaldrug use may also increasedue to 1. Carrol, R.L., "Effective Use ofheightened drug detailing and patient Corticosteroids in Allergic Rhinitis",demands and this will againt affect sample Medical Progress,May 1985.size determinations. 2. Mackay, lan S., "Topical MedicalManagement of Allergic Conditions ofDDDs will have to be re-calculeted the Nose",in Nasal Allergy, 1989.intwo year intervalsto monitorany increase 3. Siegel, Sheldon C., =TopicalIntranasalin exposure rates to these drugs. Patient Corticosteroid Therapy in Rhinitis",complianceratesmay vary oncethe entry of Journal of Allergy and Clinicalexpensive antiallergydrugs makes steroid Immunology,Vol. 81, May, 1988.

Present day obturators are made upof two parts: (1 the palatal section, whichcarries artificial teeth as well as wires knownretained by means of mechanicalinterlocking of the prosthesis to the implant.To date, no local studies have beenas clasps for successful retention to done to evaluate the effectivity of obturatorremaining dentition; and the (2) obturator prostheses constructed of locally availablesection - a bulbous portion contoured to the materials in the oral rehabilitation of patientssize and shape of the cavity - to fill the with surgically acquired maxillary defects.palatal defect (Fig.2). The design and This particular study was done with theconstruction of obturator prostheses have following specific objectives:become more versatile over the years,oftentimes incorporating more than one 1. To fabricate an obturator prosthesismaterial in a single prostheses. Provisions using locally available materialscan now be made for the inclusion of 2. To determine its effectivity in speechseparate components or sections for rehabilitationreciprocal assistance in the retention and 3. To determine its effectivity in thestabilization of the prosthesis (Watchtel, rehabilitation of deglutition1974). 4. To determine its effectivity in the:._-.._: : :. :: prevention of scar contracture:: :::::!::_::.,,..to...o=..:!: " .... METHODOLOGY:• • . •! i i • •..:. .. : : .;::.......... i....:: "_. :""::.;_=.ufi°i.n Patient Selection:/ p=h,t,.I m!c!ion_:::_:_ Thirty patients with surgically_:°la_: : : _ acquired maxillary defects seen over a one-: .... year period (January 1992-January 1993)..... , i:ii: ibluraf_or : were included in the study. They were..... '.... .::: Eeoti.n: divided into five groups based on the size of: ;i!i..._ i ......:::..-:;!::i :;i:p:al=tals,=cti=,,:: the maxillary defect.:. ii.'_;" "" ._ "_'_-.;;""""'"" "':.i'" . .ii "" i'" . Group Description Number.. ..::I H_N palatal defe¢l _JII SIP Pa,l,diml ml_lle¢lom_/ , , 12Figure 2: Obturator Prosthesis ,_ s/l:,Bilateral PadialMaxllleetornyIV S/P CompositeResectionA. Total mmdUeetomy 2/_r_talThe most popular materials used in _xerd.tatlon/Cantraprostheticrestorations include hard and soft ,,t=.,.,,.,acrylic resins and silicone rubber. Silicone ,T_=_,ooto_y_o_,.,rubber is well established as an inert _,,_,r=,o_Co°t_,-lat_'al partialmaterial and is an excellent material for the M=.,,o=o_y.,,h_o_ola_al resectionobturator section of the prosthesis owing to V Softpalatal '_efoet :Iits high tissue compatibility and its resiliencywhich allows shaping of grooves on itssurface for the purpose of retention. Group I (hard palatal defect)Unfortunately, silicone rubber is relatively consisted of patients who had less than halfexpensive and is not easily available locally, of the hard palate resected with intactHard acrylic resins, which are available portions of he alveolar margins or maxillarylocally, are used mainly for the palatal tuberosity (Fig. 3,4a, 4b). Group II (partialsection of the prosthesis. Soft acrylic resins, maxillectomy) patients had undergone aalthough not as inert as silicone, exhibits partial maxillectomy with at least one half ofgood tissue compatibility. Its wide their hard palate resected without anyavailability and cheaper cost make it a remnant of alveolar margin or maxillarypopular material for fabricating the obturator tuberosity on the resected side. Thesesection of the prosthesis. In recent years, patients were a mixed group of maxillarythe use of biochemical retention has been and palatal malignancies, with subsequentintroduced. Metallic implants placed into surgery resulting in cavities of varying depthremaining bone allows the prosthesis to be and width (fig. 3,5a, 5b). Group III (bilateral

from :: :: : ::......: : :: ileqi{inal::a:cicen:i:SParlettS: :: :: :: ::: ::::::ii : :........ _gfiosed : : :: :: : ;:: .............i!_ltSO:E.XC, d : :: .....: :............ 'u: ed .... ...... : : : ....... : : ::iii:,)Si_eS ..... :::: : ...... ::::::::::::::::::::::::::: .... .... ....... i i:i:: .... : iS::mixed::: :[:: :::: : : ::: ::: :::i : :: :i: : : : i : :...... :: ;:then: preSsec....... St 'the:: : : : : : : : :.....

modeS:,_aaeas:a::::: :::_,, ::::::::WhiCh _ :::::::::::::::::::::::::::::::::::::::::::::: .....: : : :: :: :::: : _,, .......: : ::::::::::::::::: :[::]::::::::: ::: :

Speech Evaluation:and "singsing".some of these sounds werelabeled as "indistinct" (appendix B).Evaluation of speech was done With the obturator prosthesis inpreoperatively and after fitting of the place, however, the improvement in speechpermanent obturator prosthesis six months as dramatic, with all except two pronouncingafter surgery. This was done by having the all the different speech sounds correctly.patient pronounce al list of test words The two exceptions were patients fromincorporated in the Error Pattern Diagnostic Group IV (composite resection) who afterArticulation Test (in Pilipino); and by reading extensive surgery had few availabletest sentences which form the Pagsubok ng anatomic areas for prosthesis retention.Artikulasyon sa Pagbasa ng mga However, both still obtained highPangungusap (Appendix A). These tests are satisfactory scores of 83.6% and 86.9%validated standard articulation tests used by "correct" test words with all of the "incorrect"the Speech and Language Section of the speech sounds labeled merely as "indistinct"Department of Rehabilitation Medicine. Test (table 1).words were grade by the speech pathologistas "correct", "indistinct",simple substitution", Table L Articulation Test Scores and Evaluation of"gross substitution", and "omission". All Deglutltion withObturatorProsthesiswordsjudged to be "indistinct","substituted", s_o= Alticuls_JonTe,t % S_rallot_ngSolld ObturBl.orliq_dor "omitted" were labeled "incorrect". The _o_;, ,.- . ,b_ter Betterresults were recorded as percentages of the1 100 b_er Better2 .... 100 "" b_ter , .Be_Brcorrect number of test words over the total 3 .... !0o be_ter Better100 bedter Betternumber of test words. The same speech '_ 1_ _,er tt;,e_6 100 be(ter Betterpathologist was used for all participants .._ 10_ b_tter Betterthroughout the study. Video and voice s loo ,,.*r S=terG_OUprecordings were made for each patient for ,, ....speech evaluation and documentation. _.._ 10 10o 100 better be_ter Better11 1O0 baiter BetterSwallowing Evaluation:12 100 b_ter Better,3 ... _oo _,r . pt,er14 ..... 190 . .,b,,_tF . BeBer15 1DO I_Btter BetterEach participant was allow to drink le 17 100 _ better ,,.r Better B*,.,and eat with and without the permanent _ _Do "" b=,._...19 100 bett_ betterobturator prosthesis, after which they were 20 _oo_ ,_,, ,e,erGroupasked if swallowing and drinking were the ,,,same, better or worse.21 100 b(dt_r belier22 loo b,_,_ ...b-_"er23 100 ,,, b,_"t, erbetter24 1DO beater betterEvaluation of Ease of Use: =5 . .. "' _Do ' _,,, bo..,28 100 bMte¢ betterGroupEach participant was also asked to ,_evaluate the fit and ease of use of the 27 _.oo"" ,_,, b,,ter28 1DO bMtet betterprosthesis. 2g B=.eo b.,., b°tt,, ""G(ou_pRESULTS _ ..:30 .. 100 better betterWithout the prosthesis, the Swallowing of either solids or liquidsparticipants invariably pronounced all of the without the obturator resulted in varyingtest words in the Error Pattern Diagnostic degrees of nasal regurgitation in all thepatients. With the obturator firmly inArticulation of the wordsTest pronounced incorrectly were (tablelabeled 1). Most as retention, swallowing was assessed by the"substitutes" of "omitted". The sounds most patients to be markedly improved. Nasalaffected were the plosives as exemplified by regurgitation was perceived by the patientsthe words "pusa", "bola", " gulon g, " "isda", to be markedly decreased and aspirationand "manok"; and the fricatives as was largely avoided.exemplified by the words "aso", "silya",and Three patients experienced"bus". The sounds least affected were the discomfort due to tight-fitting prostheses,nasals such as "mesa', "kendi", "itim", "ibon". which was resolved with minor revisions to""'

the obturator. Two patient in Group IV aspiration of food particles into the(composite resection) and the single patient laryngotracheal passage.in Group V (soft palatal defect) complainedof loose prostheses due to lack of adjacent With uncorrected palatal defects,anatomic areas for retention especially at the patient adapted by swallowing smallerthe area of the soft palate. The prostheses amounts of food. The diet of the patient alsowere subsequently revised to their personal tended to incorporate more liquids assatisfaction. None of the patients developed swallowing of liquids was noted to be lessmidfacial contractures, nor were undesirable difficult. With the obturator prosthesis intissue reactions experienced,place, all patients noted swallowing of bothsolids and liquids to be dramaticallyimproved.DISCUSSIONSFor the obturator prosthesis to be ofDuring normal phonation, the hard maximum benefit, it has to be comfortablyand soft palate act as barrier sealing off the fitted into the patient's surgical cavity callingnasal cavity for most sounds. Only the nasal to the fore the prosthodontist's skill andsounds (/m/,/n/,/ng/) are allowed to pass experience: What proves most challengingthrough the nose. When this barrier is is the fitting of the prosthesis into theabsent, as seen in patients with acquired extensive surgical cavities with fewpalatal defects, all sounds pass through the available anatomic areas for retention. Thenose and speech becomes hypernasal. Both presence of remaining palatal bone,vowels and consonants are affected, turbinates and most importantly, the softHowever, the most significant articulatory palate makes for better retention oferror isthe substitution of a nasal equivalent prostheses.for the fricative and plosive speech sounds.Regardless of the size of the surgical Preoperative and intra-operativedefects, their resulting impediment was consultations between the surgeon and thesignificant; as seen by their complete failure prosthodontist is absolutely necessary forin the Error Pattern Diagnostic Articulation successful prosthetic rehabilitation.Test. Frequently, the surgeon may have toremove or spare certain areas toWith a palatal defect, the Oral and accommodate the prosthesis as long as thePharyngeal Phases of Swallowing are surgical margins are not compromised.impaired. During a normal swallow, a foodbolus is formed as the tongue pushes thePrevious to the advent of obturatorfood against the hard palate. The tongue prosthesis, patients with acquir_lthen propels the bolus towards the anterior palatal/maxillary defects either were notfaucial arches by pushing it upwards and reconstructed or were reconstructed usi_ngbackwards against the surface of the hard other methods. These usually involvedpalate. In the absence of an intact hard reconstruction using various soft tissuepalate, there is difficulty in forming the food flaps. However, the surgical site wasbolus. Furthermore, as the tongue pushes obscured by the soft tissue flaps whichthe food upwards, the fragmented food precluded visual inspection for techniquesenters the nasal cavity instead of being has been developed, namely,propelled backward to the oropharynx. The osseointegrated implants. These implantsinability to form a food bolus also hampers allowed secure anchorage of prosthesesthe Pharyngeal Phase of swallowing, since and, ,more importantly, enhanced bonethe bulk of the bolus, which serves to development in the area. Its majorstimulate progression of the reflex peristaltic limitation, however, are its prohibitive costwave, is lost. The food bolus also helps to and its unavailability locally. As such, it is,protect the airway by pressing the epiglottis at present, quite impractical in the localdownwards over the laryngeal vestibule, setting.The consequent nasal regurgitation an foodfragmentation result in coordination of the The advantages of the obturatorswallowing process and may lead to chronic prosthesis are: (1) it can be made frommaterials which are readily available Ioca41y;

mrI(2) it is relativelyinexpensive;and (3) since BIBLIOGRAPHYit can easily be removed, it allowsfor easeof inspection for tumor recurrences. 1. Bowerman, J, Convoy B. MaxillofacialBecause of these advantages, the use ofprosthesis:general principles,Operativethe obturator prosthesis as the most Surgery. Head and Neck, Part I.practical method for reconstruction of Michigan,1975.surgicallyacquired palatal/maxillarydefects 2. LaneyWR. Restorationof acquired oralisadvocated, ad paraoral defects, Diagnosis &Treatment in Prosthdontics.UniversityPress,London,1983.RECOMMENDATIONS 3. Schaaf NG. Obturators on completedentures. Essentials of completeFor future studies, the authors DentureProsthodontics.vol 29=604-10.recommend: 4. Gaisford JC. Tumors of the head andneck - the who, when and how1. the use of more objective parameters in treatment. Plastic Recons-tructiveevaluating deglutition (e.g. fluorography, Surgery. 1965 36: 447-53.manometry) 5_. Watchel LW eds. Proceedings of the2. extending the study to include symposium "Dental bio-materialscongenital palatal/maxillary defectsresearch priorities"_ DHEW PublicationNIH No. 74-548.SUMMARYAn obturatorprosthesis,made fromlocally available, inexpensive materials,used in patients with surgically acquiredmaxillary defects provides successfulspeech and swallowing rehabilitation andmay decrease the incidence of postoperativescarcontractures.

APPENDIXAERROR PATTERN DIAGNOSTIC ARTICULATION TESTIn PilipinoC=Corrrect I=lndistinct SS=Simple Sub. GS=Gross Sub. O=OmissionD PLOSIVES C I SS GS O C I SS GS O " C I SS GS OA3 p" .pusa '-" ipie _, ulap ........4 b bola baboy ,.. dJbdib .....4 k kamay .... kuko manok4 q gulong ..... saging bibig15 d dahon isda likod6 t tasa mata damitFRICATIVES7 s si.lyaAFFRICATaso bus .....ES6 tsinelas kotse7 dyip ..... medyai, 2 'L'.......ASPIRAATES;i_ [ j hipon I .... 1I ' I baha_ ]L I ..... I I IGLIDES-3 w walis pakwan ........ dil,aw5 y yoyo ,. payong = tulay .....6 I Iobo ilong .. angel __6 r relosNASALSbaril ......... bapor ...3 m mesa kama itim4 n noo kendi ibon4 ngipin tenga ........ singsin_5BLENDS........... pinya .....7 bl blusa7 br braso libro7 kl klase suklay7 kr krus7 dr dram7 _tr grupo tigre7 pl plaka ........77,.£r,tr.jorutastren..........

APPENDIX BPAGSUBOK NG ARTIKULASYON SA PAGBASANG MGA PNGUNGUSAP (PAPP)(Date)Bilugan ang I, M, o F ayon sa posisyon ng pagkakamali sa pagbigkas ng titik o ponema at lagyan ng tsek ang C (correct), A(addition), S (substitution), O (omission) ayon sa uri ng pagkakamali..TEST SENTENCESVowels C A S 0/a//e//i//o//u/1. Nasugatan ang paa ng aso.M F I2. Bumilisi _E.liseong karn_e.I M F3. Isang taon na akong nakatira sa MakatLI M F4. Nakakatulog ka ba ng husto sa oras?M F I5. Masarap ang lutong ulam ni Lulu.M I FPlosives/p//b//t//d//k//g/6. Masara,g ang pasalubong ng Peloe.F ] M7. Pumasok ang babae sa Ioob ng sim_ahan.] F M8. Natapos ang pagsusulit kaninang tanghali.M F I9 _D.aratingang kapatid ni Romelda.I F M10_Malakas ang pata..kng ulan _kahapon.M F I11. Ganlto ang pagguhit ng bilog.I M FSibilant/s/12, _.ino ang nagtago ng sapato_ sa ku_sina?I F M

OSTEOMYELITIS IN OSTEOPETROSISTHE MANDIBLE THAT MANY MISSED*JERRY AGERICO B. ROSARIO, M.D**EDWARD GINES, M.D.**ABRAHAM GONZALES, M.D.**THANH VU T. GUZMAN, M.D.**GIL M. VICENTE, M.D.***ABSTRACTThis is a case report of a 33 year old female who was referred to a tertiary governmenthospital for further management of bilateral mandibular swelling of 8 years duration despiteadequate treatment. The patient also experienced limping and progressive decrease in visualacuity 4 years before admission. A sister had similar clinical "manifestations. Biopsy revealedchronic granulation tissue and osteomyelitis. Radiologic findings showed the same radiologicpicture was present in one of the daughters. Debridement to remove bony sequestra of themandible was performed.This paper demonstrates that osteomyelitis of the mandible can be an initialmanifestation of a familiar disorder of osteopetrosis. Other members of the family affected withthe disease were identified and documented.Key words: osteomyelitis, mandible, osteopetrosis, Alber-Schoberg syndromeINTRODUCTIONSwellingof the mandibleis common This paper, therefore, aims toclinicalmanifestationseen in all ENT clinics present a case of mandibular swellingin the country In this institution, it associated with other signs and symptomscontributesto 5% of all ENT cases seen at pointingto the diagnosis of a rare familialthe outpatient department and comprises disease of osteopetrosis.Secondly, it aimsapproximately 20% of all hospital to identify and document the hereditaryadmissions. Most of these cases are aspect in the transmission of this disorder.secondary to infections, and some, to thenot uncommon odontogenic and nonodontogenictumors of the mandible. ExceptCASE REPORTfor the carcinomas, these entities usuallyfollow a benign course with minimal The patient was a 33 year oldcomplications, if at all, and recovery is often female who was referred because ofthe rule. persistent, painful, bilateral mandibularswelling of 8 years duration. Initial dentalHowever, a deeper problem may consultations done with extraction of mostexist in a rare disorder that also affects of the lower teeth and prescription ofother organs of the body which may lead to antibiotics were unable to -attain permanentunexpected complications if not identified cure. Four years before admission,early. It is important for otolaryngologists to otolaryngologists at a tertiary medical centerbe aware of such disorders which may in Manila did incision and curettage andinitially manifest as an apparently common gave antibiotics, but the swelling recurredotolaryngologic problem like mandibular after several months. Repeat incision andswelling, curettage at the same tertiary medical"Presented, PSOHNS Clinical Case Report ContestApril 7, 1995, Subic International Hotel, Olongapo City**Resident, Department of Otorhinolaryngology,Jose Reyes Memorial Medical Center***Consultant, Department of Otorhinolaryngology, Jose Reyes Memorial Medical Center

4. Bronsky, Edwin A, et.al, "A Comparison allergic rhinitis", Jounral of Allergy andof Two Dosing Regimens of Clinical Immunology, Vol. 69, 1982Beclomethasone Dipropionate Aqueous 8. IMS, December, 1992Nasal Spray Flunisolide Nasal Spray in 9. Louie Wei, Astra, Philippines productthe Treatment of Acute Seasonal manager. Personal communications.Rhinitis", Immunology and Allergy 1991Practice, Vol. 34, No. 2, May, 1987, pp. 10. Philippines Statistical Yearbook.11-16. National Statistical Coordination Board.5. Kabayashi, Roger H., et. al, 11. Demichiei, Mark E. and Lois Nelson,"Beclomethasone dipropionate aqueous "Allergic Rhinitis", American Familynasal spray for seasonal allergic rhinitis Physician, April, 1988, pp. 251-263.in children", Annals of Allergy, Vol. 62, 12. Howarth, P.H., "Allergic Rhinitis: AMarch, 1989 Rational Choice of Treatment",6. Pipkorn, U, et al, "Long-term safety of Respiratory Medicine, Vol. 83, May,budesonide nasal aerosol: a 5.5 year 1989, pp. 179-188follow-up study", Clinical Allergy, Vol 18, 13. Sales Records, Mercury Drugstore1988 (Greenhills branch)7. Siegel, Sheldon, C. et al, "Multicentric 14. Jesus Ustaris, Executive Officer,study of beclomethasone dipropionate Mercury Drugstore (Greenhills Branch).nasal aerosol in adults with seasonalPersonal communication

IPECTORALIS MYOCUTANEOUS "FLY-OVER" FLAPFOR RECONSTRUCTION AFTER EXTENDEDLARYNGECTOMY*EDGAR G. DE GUZMAN, M.D.**FRANCIS V. ROASA, M.D.***ROBIE V. ZANTUA, M.D.***ABSTRACTThe pectoralismajormyocutaneousflap (PMCF) has enjoyedconsiderablepopularityasthe workhorsein reconstructionproceduresof the head and neck. This procedure,togetherwiththe gastricpull-up and free jejunal transfer, has provided the ideal one-stage procedure andshorter completiontime, in addition to its simplicity,for a "timely entry into post-operativeadjuvantradiationtherapy. The problemencounteredusuallylies in its inherentbulkinessand inthe difficultyof tubing it. This paper aims to describea modificationof the tubed pectoralismyocutaneousflap and to evaluate the technique in terms of postoperativecomplicationsandthe abilityto swallow.In our institution,the pectoralismyocutaneous"fly-over" flap (PMCF) was employed forreconstructionafter extended laryngectomy on a 62 year-old male with a diagnosis of squamouscell carcinoma, stage IV (1988 AJCC criteria). Without tubing it, the PMCF was sutured directlyto the defect such that it formed the anterior wall, and the split-thickness skin graft formed theposterior wall of the neopharygoesophagus. No untoward complications arose except forminimal skin necrosis at the area of trifurcation both in the neck and chest donor site. Thesehealed spontaneously and completion time was achieved in 2 weeks. No evidence ofanastomotic leak nor fistula formation was noted. Barium swallow taken on the 5th month postsurgeryshowed smooth passage of barium in the neopharyngoesophagus.The PMCF offers a viable reconstructive option when it is deemed appropriate forpharyngoesophageal reconstruction. The technique is able to provide a widely patent foodconduit that does not appear to impede swallowing, It is simple, safe and within the technicalcapabilities of most head and neck oncologic surgeons.Keywords: Pectoralis major myocutaneous flap, fly-over flap, extended laryngectomyINTRODUCTIONOne of the greatest challenges that Despite technical advances infaces the otolaryngologist-head and neck surgery, radiotherapy and neoadjuvantsurgeon is the management of advanced chemotherapy, the prognosis ofcarcinomas of the hypopharynx and cervical pharyngoesophageal carcinoma remainsesophagus. First, the tumor must be embarrassingly low, with a high incidence ofadequately ablated to optimize the chances treatment failure and low survival ratesof patient survival. Second, satisfactory ranging from 20-30%.4'2Surgical ablation,reconstruction must follow so that which for many is only palliative, followedpharyngoesophageal function is restored by post-operative adjuvant radiotherapy,and a good quality of life maintained, continues to be the primary treatmentmodality. However, surgery which aims at"Presented,PSO-HNS SurgicalCaseReportContestApril8, 1995, SubicInternationalHotel,OlongapoCity**Resident,DepartmentofOtorhinolaryngology,Sto.TomasUniversityHospital***Consultant,Departmentof Otorhinolaryngology,Sto, Tomas UniversityHospital

wide field ablation of the disease is A circumferential defect of 10-20frequently limitedreconstruct_by the inability to cm. in length then remains. It is advisedthat the inferior transectionat the area ofthe esophagus should be made in anThe present thrust in the overall oblique fashion and a 1-2 cm. verticaltreatment of advanced hypopharyngeal incisionshouldbe made at the anteriorwallcarcinoma is geared towards surgical of the esophagus to increase the distalproceduresthat provide one-stage primary luminal diameter, thereby preventing therepair and shorter completion time for a occurrence of stenosis inferiorly. At thetimely entry into postoperative radiation posteriorwall,the remainingpharyngealandtherapy.3 After extended laryngectomy,the esophagealmucosa are then suturedto thethree currently favored reconstruction prevertebralfascia to prevent migration ofproceduresare the free jejunal transfer, the the mucosa. A split-thicknessskin graftgastricpull-upandthe tubed myocutaneous (0.015 mm. thick) is then harvested fromflapsprincipallythErpectoralismajor flap. the innerthigh of the patientand suturedtothe prevertebralfascia to fill up the defectIn this report, a useful modification between the pharyngeal and esophagealof the tubed pectoralismyocutaneousflap mucosa posteriorly (Figure 2). This will(PMCF) repair after extended laryngectomy form the posterior wall of thefor pharyngo-esophageal squamous cell neopharyngoesohagus_carcinomawill be described. The technique....._..;_,_____/?,_.:......complications and ability to swallow. Other _.......'surgical procedures presently available arelikewise reviewed and compared with this__'i.will be evaluated in terms of postoperative,.11__i___technique and disadvantages and the functional of each are advantages likewise __i_-:.: _.... __.:._.:,._:_?._...::_._::._i _:___:_cited.An apronflapextendingfrom the,_-_; ......mastoid tip down to two fingerbreadths _il _ i:iiabove the sternum to the contralateral --i_i _?,_mastoid tip is made (Figure 1), Totalpharyngolaryngectomy(extendedlaryngectomy) usually together with an en Fig.2:Obliqueinfedorcutwitha 1-2cmantenorbloc unilateral or bilateral neck dissectionverticalincision toincreasesophagealwith preservation of one jugular vein is diametercarried out. Tissues from the proximalpharyngeal and distal esophageal remnantsThe pharyngoesophageal defect isare then submitted for frozen section then measured from the base of the tongueexamination for routine clearance of the up to the distal cervical esophagus. Theupper and lower limits of resection prior to planned cutaneous skin paddle of the PMCFreconstruction,is then marked on the lower parasternal partof the chest wall (Figure 3). It is advisable toadd 3-4 cm. of extra length inferiorly in_l ,_j._;_ i:i order to allow the flap to be rotated withouti_,, ............. _ tension to the base of the tongue. The_incision around the edges of the planned....................... pectoralis skin fasciapaddle after which is carried the down skin paddle to the__ width is sutured of the to flap the fascia shouldtobe prevent 5-7 cm. shearing Theduring flap elevation.Fig. 1: Neck incision

create a water-tight neopharyngoesophagus..... In this way, the skin of the PMCF forms thet_....__,_7_.. _[( topmost boundary while the skin graft forms__'_"_ 'k " _ the floor similar to a fly-over structure." , ........................ f_;.* 3_°_. L_[#_,L_,el .:_._t_._,,a_'=_, -..d _:_ ' . ._............:. _:_'_:::::: ....%_-_._ %', . _An incision in then made extendingFig. 3: Chest Incision I_" ' ;_ii_;iii: ....from skin paddle to the ipsilateral shoulder .....I __.%'_" _-;_*'_ ....The dissection and elevation of thepectoralis major muscle is initiated laterally Fig. 5: Pectoralis Major Myocutaneous "Fly-Over" Flapwith easy identification of thethoracoacromial vessels located underneath Suction tube drainage of the neckthe muscle. The pectoralis muscle is then and chest is then placed prior to closure ofelevated from its most distal portion in a the apron flap as well as chest donor site.cephalad direction (Figure 4). Elevation is The drains are removed selectively fromcarried out beneath the deltopectoral skin to each anatomical site as significant drainagethe level of the clavicle. The skin paddle, ceases. No occlusive dressing is placed sowith its attached muscle, is tunneled under that the vascularity of the flap will not bethe skin of the neck into the operative compromised. A tracheostomy tube (size 8)defect. Mid-clavicular resection is usually is placed. Tube feeding is commenced onnot necessary in reconstruction of the the first day postoperatively and oralpharyngoesophagus. A nasogastric tube feeding is started on about the 14th day(French 18) is then passed via the nose into depending on the clinical course. Initially,the thoracic esophagus prior toone day of clear liquid diet is started and ifreconstruction, there are no clinical evidences of..,_ ,,_ -_,_.,,, anastomotic leaks or fistula formation_ _ _i ii,,._,. I erythema, heralded and by pockets fever, of progressive fluctuance, skin the;;.; .. NGT is removed and patient is shifted to_" ,_. _'ii_,-_t_._. _ _ soft diet until the patient can revert back tol__ ;:_.._"_ i_._:._ '_'_: ............... ,_ _t'the usual feeding.-_i_'ii i_:i''_::i_'_/__' '_ CASE REPORT_ _ A 62 y/o male presented with an 18-_:., .v_ month history of progressive difficulty ofswallowing initially to solids later to liquidsFig. 4: Elevation of Pectorali$ Major accompanied by hoarseness and frequentaspiration. Barium swallow revealed anThe PMCF is then sutured directly irregular mass at the proximal esophagus atto the prevertebral fascia laterally adjacent its transition with the larynx. On tripleto the skin graft, the base of the tongue endoscopy, a fungating non-ulcerating masssuperiorly and the anterior wall of the distal was seen at the postcricoid area extendingesophageal segment inferiorly (Figure 5) to the left pyriform sinus. Biopsy of theusing absorbable interrupted sutures (Vicryl mass revealed a moderately differentiatedor Dexon 2-0). A second layer closure squamous cell carcinoma. Surgery wasbetween the pectoralis muscle and lateral advised but the patient opted forprevertebral fascia is recommended to radiotherapy instead. The patient went

home for eight months without complying esophagus extending from the inferiorwith radiotherapy only to be re-admitted borderof the cricoidcartilageto the thoracicbecause, for about a week pdor, patient inlet. Tumors arising in these two areascould not swallowanythingat all andis now may spread unimpaired from one site orwilling to undergo surgery. On indirect region to another because boundarieslaryngoscopy,a nodular mass was seen at between them merge imperceptively.the posteriorpharyngealarea extendingto Furthermore,these areas share a commonthe left pyriform sinus obscuring the pathway of lymphatic drainage to cervicallaryngeal introitus. Multiplenon-tender25- posterior pharyngeal, paratracheal, andcentavo size lymph nodeswas palpatedat mediastinallymphnodes(Figure7).the left submandibular and posterior ......................cervical area. On CT scan, a soft tissue =" ................................... _, " .....invasionof of the adjacent the caretidprevertebral sheath and fuzziness fascia. !'.:':_:-_:-'_. ................._i: _ .............. " _:ii--_ ;i _.'-;-_I _...:_!_!' _ -i_--_-'.........................stage IV. The patient underwent extended iiii, ..... ............mass onthe left side of the neck at the level _i _',.-..i: i_,_! .::-_"of C4 - C5 was delineated with evidence of ........._._:.:_ ..................__.................._..'_s_.__._=,:._ L,._- ::.-_-:_laryngectomy and left radical neck _::. ,_:dissection with neopharyngoesophageal _:_:::, ._- ..........._;_reconstruction using a PMCF. Post- "-":::_- '........ -_operatively, arose except no for minimal untowardskincomplications necrosis !i Ii¢:_the area of trifurcation both in the neck andchest donor site. These healed Fig.6: Anatomy of the Hypopharynx viewed from thespontaneously. After 2 weeks, the patientposterior aspectcould tolerate general liquid and soft diet. _.and by the next day, was shifted to a regular _:-_... iJ.::diet. There was no evidence of anastomotic_-_.:._::;:_:_ ._.i:%1:i ..:il; "leaks or fistula formation. Five months, i:. i_.:._:_:::..........._.._-_.-_.._.--_, _: :!-::: _t: _;. ,':_:.-:-:-'.:_;__ _....postoperatively, the patient was doing well=:,'-::_.-_, :;,._ .... _._:_ :_.:_" ............_....... ..., .:.,,and had completed postoperative adjuvantradiotherapy. A barium swallow delineated ':_,i_., ......._;;:,....... _.!.................-:-i_, -, i i _............ "smooth passage of barium through the __:::......_ _-:',..,,,,.,:_._,.,,.. :i:..;,_:. ..,_. ,_..... _,_ ..-,neopharyngoesophagus without any ......... _.,, _ ....................................._:..:i_:_i'_"_, '_i! ............evidence of post-radiation necrosis. Patient ....... :.-:_,-_:_,-:,,:_-_._;_:...._,_...........was then lost to follow-up until on the 9th_,_-_-_ ;.t,._..• t,_"_month post-surgery, patient developedrecurrence manifesting as enlarged mass.-,,:.i.!_...............................over the dght jugulodigastric area and Fig.7:Lymphaticdrainage of hypopharynx andcervicaldysphagia to solids. Patient underwent esophaguschemotherapy but did not complete thecoursebecauseof weaknessand eventually Stage III and IV squamous celldied of the disease2 years post-surgery, carcinomasof the hypopharynxand cervicalesophagus are associated with extremelygrave prognosis. Since the hypopharynxisDISCUSSIONa relativelysilent area, tumors here tend toattain advanced stages before symptomsThe hypopharynxis that portion of appear and get detected. The disease isthe pharynxextending from the level of the aggressive with a tendency to extendhyoid bone to the beginning of the directly into the soft tissue of the neck,esophagusat the lowerborderof the cricoid laryngeal cartilages, thyroid gland, andcartilage. It is subdividedinto the pyriform mediastinum. Submucosal extension andsinus, the post-cricoid area, and the development of skip lesions are commonposteriorpharyngeal wall (Figure 6)_. The resulting in underestimation of the truecervical esophagus is less clearly defined magnitude of the disease. There is earlybut is regarded as that portion of the metastasis to regional lymph nodes and ahigh incidence of distant metastasis5.

multiple operative procedures, and theMany oncologists and head and resultant long completion times renderedneck surgeons feel that combined radical these procedures less popular.surgery and post-operative radiation therapyprovides patient's thediscomfort, best chance for providing alleviatinggood the .... -.......-...._=ipalliation even when cure is unlikely. :.:i.._._..i_ -._ii_-_ :_Surgical ablation in advanced _':_i.:,i_;::_ >"'_'"_\"hypopharyngealcarcinomausuallyrequires ........_.•:"_" .......... "__i_;?).:"_.,.extended laryngectomy. The indications for _ .,_-- j\_. _ _ :, _:',,doing extended laryngectomy are: 1•:_!!:i_"_:_. ,L. - ..•x..-..._--.._i_ L_I__-:.-_:

techniqueto produceeffective vibrationsfor The principal advantage of thespeech. The GASTRIC PULL-UP(Figure PMCF (Figure 11) over the enteric10), onthe otherhand, doesnot requirethe procedures for reconstruction is itsspecial expertise of a microvascular simplicity. The PMCF has becomepopularsurgeon. It can also be used for because it is versatile, constant, simple toreconstructionindependentof the extent of raise, and provides excellent protectiontoesophageal resectionand with modification, the carotid artery after routine neckmay be brought as high as the nasopharynx, dissection. However, when transferring theSwallowing as well as development of flap as a tube, it is difficult to approximate itneoesophageal speech appears to be superiorly to the pharynx and inferiorly tofacilitated by the gastric pull-up the esophagus where stenosis and stricturereconstruction. The drawback is that it formation may occur_entails blind extrathoracic esophagectomy,pyloromyotomy, and pharyngogastricanastomosis in the neck..... _. _;" _7......_ i-, .-¢.".7"_.:""- ;." ._'_ .. / "........ _ t _'__._'.Fig, 9: Free Jejunal Flap. An artedalizedsegment ofFig, 11: Tube Pectoralis Major Myocutaneous Flap. It isbased on the thoracoacromial arteryjejunum can be transferred to the neck by theuse ofmicrovasculartechniques, The technique described in thisreport is even simplerthan the tubed PMCFreconstruction_ The PMCF forms the,:..'. -...:......_ _._ _ anterior wall and the split-thickness skin._.... _ ........... -,., .o_.#,.,, graft forms the posterior wall of the:! _::_ _!:i_."J..._%, i. neopharyngoesophagus. Theogaraj, et ali! :iii_:_: :. !_ ._ _._-_ _.'_ ._ first reported the use of a partially-tubulated_ ;,,..,.:. ..... _ _,_._:. :_. pectoralis muscle flap over preserved:i ;....... ,"_. ";_i:i_, ;i .f _i :_. iiJ;-....;:;= ._-.i ,,::-posterior wall cervical esophageal mucosa.... /_''."ii _ :_ ,_. in cases of short-segment stenosis3.-....._..-_' .'_ " " _':-,.. Encouraged by these results, Fabiani_ reported a technique using partial tubulationinitially for long-segment stenosis and lateri .. ,jFig. 10: Gastric P_ll-up. Based on its rich vasculatfty, expanding the indications to include thethestomachusually passes through therepair of the defect left after ablation of thepostedormediastinumin thepull-up laryngopharynx and cervical esophagus.procedure, These reports cite esophageal stenosis,although minimal, as a commonWhile the two enteric procedures complication. Maddox, concurrentlymay have their advantages in terms of reported a similar technique which left thefunction, it can not be denied that both have prevertebral fascia uncovered allowing itdrawbacks. Both are lengthy and cause merely to re-epithelialize.considerable high morbidity and mortality.

Such entails some time to completelyheal ................... ..My ......... "Ply-_v,t'F._[ ...... I_ ........especially with big defects and feeding is _ .,,.o_ ,_ITF/S C_AS,q ... 0_,'L_ TIME..................... tlON5 _delayed possiblyexplaining the 30% fistula 1 PVflf0f_ Tj,I_MR 30d_ys tl_.d. , ..... '_-OT3formation in the series1°. Lore, likewise _L_(,v, ....... "°° (".........published in a recent atlas another similar_e,,oprox_:lk_ 21 dd¥_ u(levwnlul 5 mos po_loptechnique, using dermal grafts instead of*_ep_lgu.split-thickness grafts to cover thepharyngeal wa I_.1'posterior _ _.,o".......,_.o_'_'.......__....The modification in this technique ........cDrdcenters on the prevention of esophageal , _o,_. ,,_._ ............. :'_m°a.......stenosis. By cutting the cervical esophagus ........ ,e,_°,, 'obliquely and making a 1-2 cm anterior _;_.:,;__svertical incision, the pectoralis major flap isinterdigitated to the esophageal remnant,Patient 2 developed transient fistulathus increasing the inferior diameter to more on the 7th day post-surgery. This eventuallythan 50% of the original. Inspired by the healed with conservative management.encouraging result of the first case, the "fly- Completion time was achieved 30 daysover" PMCF was employed in 3 subsequent post-surgery. No complaint of dysphagiapatients with stage IV disease of the was reported two months post-surgery.anatomical sites listed (Table I, II and III).Patient 3 developed fistula on thepX _ _ .... _......... ;,o_ 10th post-op day. This healed with_'_ _,,.......... .#, Th£ p,v, _2n_ "_' _°,_ conservative management and completion,_. _ ,, (-} ,-, {-, {., ,_ (-, (-, time was achieved 45 days post-op. Two,_ °'_ "' .} (" _*_ "' =_ _' {-_ {' {-_ (" (-_ "' (-) ") (-_ months after discharge patient was4. _O,M (+) {-) t+) (+1 (-) (') (_) {-)FDJapparently doing well with no signs of'°.............................................dysphagia.Tabll II. Manl_l_M_t for 4 _tl_tl With _tat_ IV _l¢_se of thl _t_llt_lcld _lte_ li_ted."7_ _ ............. M ............... With patient 4, radial free flap was..................................., _xt [pp¢_ El_ph_gu_•_..........i_ryng_clomy.used instead of split-thickness skin graft to.".%1:_ cover the posterior wall. The patient initiallyusln_........mejot "Flyshowedsigns of rapid recuperation until..., .__'_ patient developed icterisia and ascites onE_e_ded2 MA 68/M pwtfocm _Inu_ T_N_M_............................ ,_._,,r,o., the 10th post-op day which was diagnosed_,_; .... to be a diffuse parenchymal liver disease.pecIorallS..... -.... There was wound dehiscence and fistulao_r-__o_ _,_ ........;_i>d Io I1_Vocalcord_""_ _-_"°_'dI_yr_clom¥.formation which was treated withBll_teral neck............. debridement and antibiotics. Completion;:;_..... time was not, however, assessed becausema_or 'Fly.,_,.,,_ the patient died on the 32rid post-op day.E_dFDJ - _ _ I_R_cel cord and _,'_n_ectomy,_r_t_t_sel*a_er_ neckcord =(STAGFr_abQnm_loro_r" ._p-Fly.

The functionalresult was excellent 3. Fabian, R.L. Pectoralis Majorin terms of swallowing. However, as in Myocutaneous Flap Reconstructionofother types of pharyngoesophageal the Laryngopharynx and Cervicalreconstruction,esophageal speech has not Esophagus. Laryngoscope, 98:1227-been attained to date in these patients 1231, 1988.although all can produce some sounds. 4. Thawley, SE, Sessions, D.G. SurgicalPatients who undergo extended therapy of hypopharyngeal tumors. Inlaryngectomy with PMCF reconstruction can Thawley, S.E., Panje, W.R. (eds.):usually be subjected to radiation therapy Comprehensive Management of Headquite early at approximately 30 days post-and Neck Tumors. Philadelphia, W.B.surgery. As reported by many authors, the Saunders Company, 1987, pp. 774-812.mortality rate of zero and the low incidence 5. Gluckman, J.L., et. al. Partial vs. Totalof significant postoperative complications Pharyngolaryngectomy and Cervicalsuggest that PMCF reconstruction is a Esophagectomy with Jejunalviable alternative to one-stage Autotransplant Reconstruction.reconstruction using gastric or jejunal Complications and Results.transfer considering that the two enteric Laryngoscope, 98:911-914,1988.procedures are more complex, life 6. Mc Connel, F.M.S., Logemann, J.A.threatening, and extremely morbid. Table Diagnosis and Treatment of SwallowingIV summarizes the comparison of these Disorders. in Cummings, C.W.,reconstructive techniques.Fredrickson, J.M., Harker, L.A,, et. al.(eds.): Otolaryngology-Head and NeckT......... ,,......... _,...._e¢onltlv¢ Techrd¢_Lit't_tl_on_Surgery, Update I1. St. Louis, Mosbyr_-- Mort_dltV C_mplebon..................Proco_ur_M_rt_l),Year Book, Inc., 1990, pp. 10-38..... _,_", .......... ,, ...... _y' ,_ .... 7. Guillamondequi, O.M., Larson D.L.,,....., ,,_._ ,,,_w.o,_ . Geopfert, H. Reconstruction of theP_up . .sur_,_, _ ...... ,,r....... ,_........... Hypopharynx and Cervical Esophagus,(TLIb_edF IIIp IIJ_ . :._-_, FLAP _,_ _o__,_ {.'_EFECTS _, ...... NIL _o,_ In Bull, T.R., Myers, E. (eds.): PlasticReconstruction in the Head and Neck.England, Butterworth and Co.The technique of (Publishers) Ltd., 1986, pp. 31-52.pharyngoesophageal reconstruction 8. Schechter, GL., Baker, J,W., Gilbert,discussed here is SIMPLE and SAFE, a D.A. Functional Evaluation oftechnique within the technical capabilities of Pharyngoesophageal Reconstructionmost head and neck oncologic surgeons of Techniques. Arch. Otolaryngol Headevery discipline. The technique is able to and Neck Surg, 113: 40-44, 1987.provide a widely patent food conduit that 9. Ferguson, J.L., De Santo, L.W. Totaldoes not appear to impede swallowing. Pharyngolaryngectomy and CervicalAlthough it is not suggested that it be used Esophagectomy with Jejunalroutinely in preference to jejunal transfer or Autotransplant Reconstruction:gastric pull-up, this technique is a useful Complications and Results.alternative when a PMCF is believed to be Laryngoscope, 98: 911-914, 1988.the appropriate form of 10. Maddox, W.A., O'Brien, C.J., Bragg, L.,pharyngoesophageal reconstruction. Urist, M.M. Total PharyngealReconstruction Using a PectoralisMyocutaneous Tunnel. Arch Surg, 123:BIBLIOGRAPHY 391-393, 1988.11. Lore, J.M. An Atlas of Head and Neck1. Lau, W.F., Lam, K.H., Wei, W.I. Surgery (3rd ed.). Philadelphia, W.B.Reconstruction of hypopharyngeal Saunders Company,1988.defects in cancersurgery:Do we have achoice?Am J Surg, 154:374-30, 1987.2. Coleman, J.J. Reconstructionof thepharynx after resection for cancer: Acomparison of methods. Ann Surg,209:554-561, 1989.

PREDICTIVE VALUE OF CLINICAL SYMPTOMSNASOPHARYNGEAL CARCINOMA*INDIOSDADO C. UY, M.D.**CHARLOTTE M. CHIONG, M.D.***ABSTRACTA five year retrospective study was done in 69 patients who underwent biopsy forsuspected nasopharyngeal carcinoma (NPCA) at the Manila Doctors Hospital from 1989 to 1993to determine if clinical characteristics were predictive of the outcome of the biopsy. There were33 negative and 36 positive malignant biopsy results. The clinical characteristics found to besignificantly associated with NPCA were nasal mass, nasal obstruction, neck lump, hearing loss,ear fullness or pain, upper respiratory tract infection (URTI), cigarette smoking, weight loss anddiplopia. Age, gender, family history, head and neck pain, and epistaxis were not consideredsignificant predictors of malignancy.Keywords: Nasopharyngeal carcinoma, predictive valueINTRODUCTIONDuring the early stages, these tumors permitonly subtle and seemingly trivial clues ofNasopharyngeal carcinoma their existence such that they remain(NPCA)is a relatively rare neoplasm in the overlooked until too late in their course.population at large with an overall incidence Delay in diagnosis of about eight to nineof only 0.0005%. Among Caucasians in months has been attributed to these highlyNorth America, it comprises merely 0.25% inconsistent clinical presentations 3'6.of all cancers. It has been found to have thegreatest frequency of occurrence among the The location of the primary tumorChinese at 18% 1'2.Populations with Chinese and its direction of spread determines thegenes been found to have a higher clinical behavior of these very destructiveincidence of NPCA 1, Martin and Irean noted neoplasms. Hearing loss and a lump in thea racial susceptibility among Orientals, neck have been the most frequent reasonsexcept the Japanese, in their for seeking medical consult 1'2'7. The finalinvestigations 3. Indeed, anecdotal report outcomes of the disease in such instancesattests to its relative frequency in the have been usually fatal. It is of greatPhilippines. Local tumor registries confirm importance, therefore, to be able toits relatively high occurrence rate 4. recognize the existence of thesemalignancies during the early stages whenNPCA presents a bewildering array successful therapy is far more likely 8.of sign and symptoms from the onset of thedisease to its potentially grim conclusion. Its The main purpose of this study is tobiological behavior appears to be uniform in identify the different socio-demographicall races _'5'7. The clinical profile of the variables and clinical features used intypical patient has been too intricate and profiles of NPCA, and to find out which ofnonspecific to be of much predictive these clinical findings correlate withvalue 5'6. More often, these symptoms malignancy based on nasopharyngealmanifest themselves in both malignant as biopsy. In so doing,-a pattern of clinicalwell as benign and inflammatory conditions, signs and symptoms can emerge which can"Presented, PSOHNSDescriptiveResearchContestOctober27, 1995,HolidayInnHotel,Manila** Resident, Department ofOtorhinolaryngology, ManilaDoctorsHospital***Consultant, Department ofOtorhinolaryngology, ManilaDoctorsHospital

Ieventually be used as a more established was found in 36 patients (52.17%), 27 malescriteria for early diagnosis, and 9 females, while 33 patients(47.83%),18 males and 15 females hadMETHODOLOGYnegative biopsy results.A total of 98 medical records of Of the 31 patients who had positivepatients who underwent nasopharyngeal biopsy results, the ages ranged from 12 tobiopsy at the Manila Doctors Hospital during 74 years with a mean of 45.89. This broada five year period from January 1989 to range of age distribution had two thirds ofDecember 1993 were reviewed. Clinical patients falling between 30 to 59 years ofvariables as identified in foreign and local age. Age was not significantly associatedNPCA profiles were obtained in these with a positive biopsy result (p=0.5041)patients and tabulated _'4'5'9'1°.(Table II).Table ITable II, AGEThe Mayo Clinic Series of Symptoms and Signs of RANGE BIOPSY TOTAL.. (+) ... ('),L, NPCA at Diagnosis, "'1'0-19 3 ,, , J 0 31.necklump 60% 20-29 2 5 72. ear fullness or pain 41% 30-39 ... 5 .6 i 13, hearing loss ..... 37% 40-49 9 ., 9 184. nasalbleeding 30% 50-59 9 8 175. nasalobstruction 29% 60-69 ,,6 3 96. neckpain,, 13% 70-79TOTAL2362334697. weightloss .... 10.%. '"XZ=5.315_. d)plopia 8%LocalReviewbyYatco,UyBLetal,1985p=.5o41i. cervicalmass 77%2. nasal,obstruction. 39% Likewise gender was not a3. nasalbleeding 35% significant variable at x2 =2.338 and410tolo.gi¢ complaintsp=0.1263 versus biopsy results.serous discharge 30%Tinnitus 16%Decreiised hearing 14% Table II1.GENDER5, diplopia . _ " 25% GENDER BIOPSY TOTAL6.head & neck pain 30% (+) (')MALE 27 18 45FEM.A,LE 9 15 24The following multiple socio- TOTAL 36 3:3 69P=0.1263*NOT SIGNIFICANTdemographic factors were evaluated: age,sex, cigarette smoking, family history, andclinical signs and symptoms; neck lump, History of cigarette smoking showednasal mass, ear fullness or pain, weight significant correlation with NPCA for theloss, upper respiratory tract infection and combined sexes (p=7.191x10 `4) but not fordiplopia. Only 69 patients were deemed sexes considered separately. Positiveadequate for analysis of data required,smoking history in males showed significantcorrelation (p=3.71x10 3) but not in femalesNegative and positive NPCA (p=0.6791).biopsies were tabulated and compared TableIV:CIGARETTE SMOKINGaccording to each clinical variable. BIOPSY TOTALDescriptive statistics (average, mean, and . (+) (-)percen-tages),Chi-square analysis and MALI_(+) (-) 20 7 14 5 25 21Fisher's exact test were employed whenever TOTAL 27 " 19 "signific 46 " 'necessary to establish significance as a P=3-716x1°-_ antpositive predictor of malignancy. FEMALE (-) (+) 27 13 i' 20 3TOTAL 9 14 23Fisher's "_Exact*notRES U LTS Testp=0.6791 signific antThere were 69 patients included inthe study, 45 males and 24 females. A Among the 69 patients reviewed,positive malignant nasopharyngeal biopsy only 1 patient had a family history of cancer.

The correlation between upper respiratory Hearing loss in 30 patients, 23tract infection found in 30 patients, 21 positive and 7 negative biopsies, waspositive and 9 negative biopsies, was significantly correlated with NPCAstatistically significant (p=0.0184). (p=8.713x210) (table IX).TABLEV, URTITABLEIX, HEARING LOSEBIOPSY TOTAL BIOPSY _rOTAL_*) {-) (*) (-)+ 21 9 3015 24 39 + '" 23 7 L 3(]... ,,,.TOTAL 36 33 69 13 26 39P=0:0184*SIGNIFICANTTOTAL= 36 33 "69x2=11.083 _ SIGNIFICANTComplaints of a lump in the neck in P=8.71341 patients, 27 positive and 14 negative xl°_biopsies was significantly ocrrelated withEpistaxis among 34 patients,22NPCA (p=0.0122) (Table VI).positive and 12 negative, was not significantTABLEVl- NECKLUMP (p=0.0698) (Table X).BIOPSYTOTAL(+) (-) TABLEX.BIOPSYTOTAL+ 27 i4 41 " (+) (.)9 19 28+ 22 12 34TOTAL 36 33 69 13 21 35xZ=6.287 TOTAL,, 36 33 69P=0.0122 *SIGNIFICANTx2=3.287 *NOT SIGNIFICANTNasal mass in 43 patients with 32 P=o.oegspositive and 11 negative biopsies wassignificantly correlated with NPCA Forty-three patients had a complaint(p=6.532x 103)(Table VII). of nasal obstruction. Of these, 31 patientshad positive biopsy and 12 had negativeTABLEVII.NASALMASS biopsies. The correlation was significantBIOPSY TOTAL (p=2.094X10 -4).(Table XI).(+) (-)+ 32 11 ' 4_3 TABLE XI. NASAL OBSTRUCTIONBIOPSYTOTAL4 22 26 (+) (.)TOTAL = ""36 33 69 +" 31 12 ' 43x2=20.326 6 20 26P=6.532X 104 *SIGNIFICANT TOTAL= 37 32 69Fishers P=! .721xl0 "6x2=13.745Ear fullness or pain was present in P=2.094X10_33 patients, 22 positive and 11 negativebiopsies. The correlation with NPC was* SIGNIFICANTsignificant (p=0.0388) (Table VIII). Head and neck pain in 44 patients,TABLEVIII. EARFULNESS/PAIN 27 positive and 17 negative biopsies, was• BIOPSY TOTAL not significant(p=& 1445)(Table Xll).(+) (-)+ "22 11 ;33 TABLEXII. HEAD/NECK PAINBIOPSY14 22 36 {+) (.)TOTAL= 36 33 69TOTAL+ 27 17 44x2=4.269 * SIGNIFICANT 10 15 25P=0.0388 TO'I:AL= 37 32' 69 ' 'x2=2.130P=0,1445*NOT SIGNIFICANT

Epistaxis is one variable which statistically significant will enable us tosurprisinglydid notturn out to be significant, predict with greater confidence theConsideredto be a late sign in NPCA, it possibilityof a naso-pharyngealmalignancyindicatesa massive space occupyinglesion whenever their presence is noted.with pressure necrosisand fungation3'9'1°'12. Moreover, not so common symptoms whenIt is a question when to take into account present become significant in the light ofthe number of patients who complained of findings of this study. Specifically, theblood tinged sputum, suggesting post nasal presence of weight loss and diplopia in ableeding, and if this will affect its overall patient when associated with the othersignificance. On the other hand, epistaxis significant variables identified warnis a common symptom in various benign clinicians to be highly suspicious of aconditions and might, as the results possible NPCA. This will spell the differencesuggest,be consideredwithcaution,between doing a single biopsy or multiplebiopsies to patients highly suspected toHead and neck pain is a clinical have NPCA.symptom of sundry physical conditions andis not necessarily specific for malignancy.RECOMMENDATIONSThis study shows this to be the mostcommon complaint at 63.76%. However, A multiple regression analysis ofthis was not significantly predictive of a these variables in a prospective study ispositivebiopsyresult,recommendedto define the true predictivevalue in diagnosisof NPCA in Filipinos.Symptoms of weight loss anddiplopia, not withstanding theiruncommonness, were found to be BIBLIOGRAPHYsignificant predictors of NPCA.1. Cummings CW et.al, ed. Otolaryngology Head & NeckSurgery vol 2, St.Louis. CV Mosby, 1993; 1361-71.Diplopia results from the superior 2 Donald P. Head and Neck Cancer Management of theextension of the tumor through the foramen Difficult Cases.PhiladelphiaWB Saunders, 1984;295.lacerum, an unimpeded pathway near the 3, BatzakisJG. Tumors of the Head & Neck. Clinical andPatho-logicConsiderations2 ed. Baltimore.Williams andRosen-muller's fossa into the cranium, Wilkins, 1979;188-99.re6ultingin external rectusparesisfrom the 4. Baltazar J. CancerRegistra-tion in MetroManila,involvement of the sixth cranial nerve18. Statistical Report,1975-1977, TheCentral Tumor Registryof the Phil.Thiswas considereda late sign in NPCA. 5. Paparellavol3Philadel-phia.MMetaled.OtolaryngologyWB Saunders,1991: 2193-98,6. Adam GL, Boles LR. Boeis' Fundamentals ofAlthough studies of clinicalprofilesOtolaryngologyed6 Philadelphia, 1989.of NPCA patients have been described in 7 DicksonHI. NasopharyngealCarcinoma,An Evaluationof209 Patients.Larygoscope1981;91:333-54.andNasopharyngeallocal literature, no systematic analysis of s. Prassad U.FossaofRosenmullertheir predictive value of these symptomsCarcinoma, MadJMalaysia 1979; 33:222.have been analyzed. 9. Yat¢o MM, Uy BL, Clinical Profile of NasopharyngealCarcinomain Filipinos.The PhilJ Oto HNS 1985; 371-78.10. Uy BL, Clinical Profile of NasopharyngealCarcinoma inCONCLUSIONS Filipinos.The Phil J Oto HNS 1986;46-46.11. Nell HB III, Taylor YF. Clinical Presentation and DiagnosisofNasopharyngealCarci-noma. CurrentStatus. inPrassad U et al ads: NasopharyngealCarcinoma,CurrentConcepts, Kuala Lumpur, 1983, University of MalayaResults of the study show that notall clinical variables routinelyconsideredinPress.epidemiologic profiles of NPCA are 12. HoppingSB etal, Nasophary-ngealMasses inAdults.Annsignificant predictorsof the disease,otolRhinol Laryngo11983; 92:137-40.13. Fletcher Ga Millian RR. MalignantTumors of the Nasopharynx.AmJ Roentgenol1965;93: 137-44,Frequency of occurrence of a 14. EnglishGM ed. Otolaryngo-logy,A Textbook Harper andRow, 1976.variable does not correspond to a higher 15. LeeKJ.Essential Otolaryngo-logy, ed 5, NewYork,incidenceof malignancy. ElsevierScience Publishing,1991: 509,16. De Vita V. et al. Principles & Practice ef Oncology.Cancer,JB LippincottPhiladelphia1982: 365.These so called statistically 17. West S, Hildesheim A, Docemeci M. Non-Viral Riskinsignificant variables that are present in FactorsforNasopharyngealCarcinomain the Philippines,Resultsfroma Case ControlStudy.Int J Cancer 1993; 55both malignant and non-malignant (5):722-7.conditions. On the other hand, those lS_ ApplebaumEL, UantravadiP, Haas R.signs and symptomswhichwere consideredLymphoepithelioma of the Nasopharynx. Laryngoscope1982;92; 510.

There were 14 patients who The 3:1 male preponderancein thissufferedfrom weightloss, 12 positiveand2 study is also consistentwith the findings ofwho had negative biopsyresults, showing previousinvestigations4'16.signi-ficantcorrelationwith NPCA (Fisher'stestp=4.793x103('rable XIII). A positive history of cigarettesmoking of about 30 years had beenTABLE XlII. WEIGHT LOSS associated with nasopharyngeal(+) BioPsy (-) TOTAL malignancies, the incidencerising 7.2 foldcomparedwith controls17. This factor was+ 12 2 1424 31 55likewise significantin our study.TOTAL= 36 33 6S Although among 69 patientsFlsher'sl_4.793xX10 _ *SIGNIFICANT reported in our study, only 1 with a positivebiopsyresulthad a family historyof cancer,Diplopia in 12 patients, 10 positive one cannotdiscardthe influenceof geneticsand 2 negative biopsy results, was altogether, bearingin mindthe possibilityofsignificantly correlated (Fishers test under reportingandlack of awarenessaboutp=0.0375) (Table XIV).the disease16.TABLEXIV.DIPLOPIA The inclusion of recurrent upperBIOPSY TOTAL respiratory tract infection as a variable is(+) () unique to this study. This was because of+ 10" 2 12 compelling evidence linking the Epstein-29 28 57 Barr virus, long known to cause chronicTOTAL=, 39 30 S9 rhinosinusitis, with NPCA1'3'17'18. Trueenough, it proved to be a significantsignFishers ExaotTeatP=0.0375*SIGNIFICANT associated withmalignancy.DISCUSSIONNasal mass and nasal obstruction,the two most common symptomsfound inthis study at 46.37% and 44.92%Table IB shows the common and respectively, also figured prominentlywithnot so common symptomsof NPCA in the that of the Mayo Clinic sedes (Table I) andstudy population. These includes nasal were found to be significant predictors ofmass and nasal obstructionwhich were the malignancy.two most common symptoms. It supportsBatsaki's contention that cancers of the A lump in the neck was thenasopharynxtend to extend and proliferate commonly reported symptom in NPCA inearly into the nasal cavities5'_'_2. Local the Mayo Clinic study at 60% frequency.studies by Yatco MM and Uy BL had Although it is considered a significantcervical mass as their earliest presentingvariable in this study, it only ranks third insign with serous otitis media, nasal the orderof frequencyat 39.13%.obstructionand bleeding coming next9'_°.Otologic symptoms(ear fullness orFletcherneck asandtheirMillianmostreportscommona lumppresentingin the pain and decreased hearing) were allsign13, significant manifestations variables are ina this result study. of These tumorThe mean age of our patients at invasionof the lateral nasopharyngealwall,48.5 years, is comparablewith that of local near or directly involvingthe mucosa of theand foreign literatures3'_°'1_.The frequency Eustachian tube orifice or partk;ulartydistributionconforms with those of studies Rossemuller's fossa, leading to tubalwith Chinese subjects showingthe highestserousmalfunction,otitisa sensationmedia andof earultimately,blockage,incidence amongthe 40 to 69 age groups.This is in contrast with the bimodal conductivehearingloss1'7's.occurrence in Caucasian at ages 30 andunder to 80 and above_4'_5.

::b::::-L: : : :"""-%-- " :: ::':TL : ..... :: ....... : ...... " - " "/ / "L:: "- : :-v ¸¸ "" : : : : - L .....: ::i:i ......... : repress tO : ::deiisider metastasis aie:a from irute out a :t'e_ :[ma gna_c:y f%n the::: : :::aerod gesive tiiact: : : : :: :: ............................ : : : ..... :::mass :on : :........ :: Under: ::anestheSla,, the .....: : .....:e×iending:: :::::: ::::nas:o:ph::aN:n×_ag exam ned us ng Hopk n s : :. i_optia[iynx:(figi:i a bulge noted on the ........:::::::'::::::: eal masS: WaS: ::::I::igN:post e'_01!:wa Wth _']nma:mucosa, :Sh:oWed ::: :: :re.q.ua:tes PuiiO_t bopsy specmen were :: : :at foil T alig_:ial:Cy: : : ::o:bta led from ::iti:S::bt as: we i aS f'o n the : :i!0wtti Oi tiie:: laieiiai: ::: ::::: and::esophaqoscopy :: : ::::were were esi;entiatty[: : : : :::::wall of: i!i:ght::t*achee_bronch a .i. qct o 1.... ...... :i'lart:ai: obstruction. Another .................... :: :: :::: : : specimen:was::_aken-fromtqS:masS : ...... :..... : : : :..... ,path0ogic exam:_atot : ::_ : ::::::secti0ns 0f:ailthespecimen :show mucous : : :::::::: :: :: membrane ned: CokJmnalt:,ciiiated cetlStratified:sqcamous epthe (.m (;ont-aryorto: : ::::::: expectatiOnS:,::: _tier@ is nO :evidence: of : : ::: :malignancy,: h_Stead; within: : the lymphoid ::::::::::::::::::::::: 2....: These cells : : :........ were::sun_ounded:::by a:cea

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B. It involved extensively the of this extensive involvement, the patientretropharyngeal space from the did not presentclinicallywith any symptomsnasopharynxto the hypopharynx,as well as of pharyngeal compression, such asthe right tracheo-bronchialjunction.Despite dyspnea, dysphagia nor neck pain. Mostthis, however, the patient does not probably,it had been a very slow-growingexperience symptoms of compression or mass such that the patientwas not able toobstruction, perceive the minute increments inpharyngealswelling.C. While cryptococcus more commonlyaffectsthe immuno-compromised, this case Why this particular case ofa non-immunocompromisedpatientwith foci Cryptococcosis manifested as aapartfrom the brainor lungparenchyma, retropharyngeal and lateral neck mass isindeed intriguing. There is good evidenceHaving a one-sided lateral neck to assume air-borne mode of transmissionmass is certainlyan atypical presentationof of aerosolized droppings, entering througha cryptococcalinfection. Usually, high in the nose,depositedin the nasopharynxandthe list of differentials for the patient'sage the tracheo-bronchialjunction, with fungusgroup would be a malignant lymph node lodginginthe terminal airway. From there,metastaticfrom a ibrimarytumor in various it candisseminateto any part of the bodybyareas of the head and neck, especiallythe hematogenous, contiguous or lymphaticnasopharynx. It could also be a primary spread3_lymphoma, in the Philippine setting, thetuberculous lymph node is a top In this case, the predominant modeconsideration among the granulomatous of spread might had been lymphatic (Figureconditions.8). The organism must have spread via thelymphatic system to the neck. Since theThe fact that the patient's chief neck is particularly rich in lymphatics, ancomplaint is a lateral neck mass is extensive involvement is very possible, and,especially unusual since this particular like it would in a malignancy of the upperoccurrence had not been encountered airway,, the condition manifested as lateraldespite an extensive literature review. This neck mass.may well be the first case of cryptococcosispresenting as a lateral neck mass reportedboth locally and internationally....._.:_....:,-,.,..,-...,,_: ,".._ .....:,::5:!!__..............There have been very few reported _ _=_:i_ithese are very localized involvements.Reported involvementof the sinonasalarea:!i_'_of_'-__include that of Kohlmeier about a caseinvolving the right maxillary and ethmoidsinusesin 1955; Littman and Zimmerman, \cases the nasal in the septum ENTin areas 1956; Briggs of interest, et al., and thenasal vestibule in 1974; and Choi et al.,,f_f_'_'_'_/_ --_ _iiii ...........pansinusitis in 19882'3'9. Earlier in 1927,Jones reported a case involving thenasopharynx9. In 1987, Korvick and Yureported a case of cryptococcal tonsillitis ina patient with chronic lymphocytic Fig. 8: Proposed route of lymphatic spread ofleukemia7. There were only three reports of cryptococcalinfection in case ofpadent Z.B.laryngeal involvement in 1975, 1989 and19922'9'1°.Karcher (1963)reports that only Another theory of retropharyngeal3% of patients with cryptococcosis present space involvement would be directwith mucosal lesions9_ extension from a primary cryptococcalimplantation in the nasopharynx_ FromThis case involved the there, it spreads to the contiguous areas, asretropharyngeal space from the well as through the lymphatic system, as itnasopharynx to the hypopharynx, another would in a case of nasopharyngealvery rare manifestation. Moreover, in spite carcinoma.

victims shows the value of T-lymphocyte-However, both of the above dependenthostdefenses12.mentioned mechanisms of spread are notthe most usual ones. More commonly, In terms of incidence, more thansilent hematogenous spread occurs, with half of the cases of cryptococcosis in thepreference for the meninges. In fact, USA are afflicted with AIDS. Among themajority of patients have cryptococcal patients without AIDS, meremeningoencephalitis at the time of than half of these are immunosuppressed5.diagnosis. Early signs and symptomsinclude headache, nausea, staggering gait, The initial mortality rate ofdementia, irritability, confusion and blurred disseminated cryptococcosis invision9, There is no clinical evidence to immunologically normal patients is 0-15%consider this. There were also no with a 35% relapse rate. Mortality in relapsecryptococcal cells seen in the CSF study, cases goes up to 75%. Inimmunocompromised patients, initial rate isWhy the infection had not affected up to 85%, rising to 100% for relapses3.the brain despite the extensive respiratorytract involvement is another mystery to This case of cryptococcosisexplain. Interestingly, in the two other cases occurred in a healthy, nonofgross respiratory cryptococcosis in non- immunocompromised patient. There isimmunocompromised patients reported nothing in the history associated with any ofearlier1°'11,there was no apparent CSF the common predisposing factors for theinvolvement. The question of whether a development of cryptococcosis. Patient hasmedically-sound explanationcoincidence exists makesfor thisfurthera normal CBS as well as a negative AIDStest.investigation warranted. Perhaps there is adistinct strain of C. neoformans that has aHowever, very massive inhalationpredilection for lymphatic spread. And since of cells may result in progressive systemicthe brain has no lymphatics, it would thus be disease in a normal person6. In 1988,spared from infections of this particular Anderson described that externalstrain, dissemination of intranasally instilled C._.neoformans in mice begin 14-28 days afterThere is usually no instillation and is still demonstrable 90 dayslymphadenopathy in cryptococcosis4. This post-exposure. Ten percent mortality wascase is a rare instance when the lymphatics observed in mice receiving 106 cryptococci,is the most likely mode of spread. Although while no mortality was observed in mice3 4 1it is often mentioned, there may have been exposed to 10 or 10 cryptococci. There isno other case report which provides such certainly evidence that the patient had beenconvincing evidence of the lymphatic exposed to what can be presumed to be aspread of cryptococcosis as this one.large amount of cryptococcal cells since thebedroom window was located next to aAlso a very important point is that pigeon coop for about 2 years.the patient is not immunocompromised.This disease rarely affects man as a primary The cryptococcal organism hasinfection. Between 40-85 percent of patients been isolated from dried pigeon droppingswith cryptococcal infections also have and nesting places and this association hassevere underlying diseases or been described since the 1950's byimmunodeficiencies (120. AIDS, Emmons2. Pigeon droppings apparentlylymphoreticular malignancies (esp. contain nutrients which makes it a goodHodgkin's disease), sarcoidosis, diabetes medium for cryptococcal growth11.Healthymellitus, immunosuppression from long persons with a history of heavy exposure toterm corticosteroid therapy or after renal pigeons have much higher rate of positivetransplant, cytotoxic drugs and therapeutic delayed skin tests to cryptococcal antigen orirradiation are the common predisposing cryptococci8.factors for the development ofcryptococcosis.2'9. The frequency of In the literature reviewed, therecryptococcal disease in steroid-treated have been only two cases reported ofpatients, allograph recipients, and AIDS cryptococcosis focus other than the brainand lung in a non-immunocompromised

patient. Both involvedthe larynx2't°'_1.This 3, This case has providedfurther evidencecase wouldthus be the only one of the very as to the lymphatic spread of cryptococcalfew documented in this category reported infection. This suggest new directions forinternationally,and the first to be reported investigationinto possible different strainslocally,of C. neoformans, one of which may havepredilectionfor lymphaticspread.(For more details aboutCryptococcal infection please refer to 4, This unique case alerts one to think thatAppendixA).Cryptococcosis can present as mass in theretropharyngeal space (without compressionsymptoms) and tracheo-bronchial junction,CONCLUSIONaside from a chief complaintof lateral neckmass, in non-immunocompromisedpatient.In summary, the case of a 49 year This is probably the first locally, if notold female, with chief complaintof a right internationally, documented and reportedlateral neck mass was presented. History case of Cryptococcosis with such unusualrevealed chronic non-productive cough and involvement.exposure to pigeon droppings. Flexibleendoscopy revealed masses in the From the bronchus to thenasopharynx and the right tracheobronchial nasopharynx via the retropharyngeal space,junction. CT scan showed a right pre- and to a lateral neck mass - this was how thepara vertebral Ioculated cystic mass creeping crypt crept.extending from the nasopharynx to thehypopharynx. Biopsy of said masses allrevealed Cryptococcal infection.BIBLIOGRAHPYThis interestingcase imparts to the i. Anderson, DA and HM Segla. Persistence of Infection inMice Inoculated Intranasally with CryptococcusOtolaryngologist-Head and Neck Surgeon neoformans. Myopatholgia 1988; 104(3): 163-169.the following very important lessons:2. Blitzer, A and W Lawson, eds. Fungal Infections of theHe_d & Neck. The Otolaryngologic Clinics of North1. This case serves to temid the America 1993; 26(6).Otolaryngologists-Head & Neck surgeon 3. Choi, S$ et al. Cryptococcal Sinusitis: A Case Report andthat cryptococcosisalbeit more commonly Review of Literature. Otolaryngology-Head & Neckencountered as a pulmonary or neurologicSurgery1988;99(4):414-418.problem, can also present or exist in the 4. cummings, cw et al. Ololaryngology-Head & NeckENT realm of interest. A patient with thisSurgery2nded. volII.St.Louis: MosbyBook. 1993.progressively systemic disease could5. Isselbacher, et al. Harrison's Principles ofactually seek consult with an Medicine 13th ed. New York: McGraw-Hill, 1994.InternalOtolaryngologist-Head& Neck Surgeonfirst,It thus becomes one's responsibilityto be 6. Jawetz, E. Review of Medical Microbiology 171h ed.Norwalk: Appleton Lange, 1987.aware of this entity to e able to correctlymanagethe infectionin the early stages. 7. Korvick, J and VL Yu. Cryptococcal Tonsillitis in a Patientwith Chronic Lymphocytic Leukemia. American Journal ofHematology 1987; 25(4): 475-478.2. When considering the diagnosis of alateral neck mass, it is essential to keep in 8. Mandell, Infectious GL Disease et al. 3rd eds. volPrinciples III. New and York: Practice Churchill ofmind the possible differentials, from the Livingstone, 1990.more common to the more bizarre. Aspractitioners of the mysterious art and9. Paparella, MMandDL$humrick. OtolaryngologyPhiladelphia: WBSaunders Company, 1993.volI.science of Medicine, one should always be10. Reese, MC and JB CoI¢lasure. Crypto_occosis of theready to expect the unexpected, When Larynx. Archives of Otolaryngology 1975; 101: 698-701.faced with a mass which on CT-scanappears like cyst/abscess, due 11. smalLman, of Laryngology LA el and al.Cryptococcosis Otology 1989; 103:214-215. of the La_/nx. Journalconsiderationshouldbe givento a diagnosis12. Tenholder, MF et at. Complex Cryptococcal Empyema.of cryptococcosis, even in a non-Chest 1992; 101 (2): 586-568.immunocompromisedpatient.

APPENDIX Acan occur in one of the three following ways:(a) tracheobronchial colonizationin certainDETAILS ON CRYPTOCOCCAL patients with chronic lung disease; (b)INFECTIONclinical or subclinical infection in a normalhost represented by a subpleural noduleAlso called torulosis or European usually in association with ipsilateral hiiarblastomycosis,cryptococcosisis caused by adenopathy and (c) disseminated infectionCrvptococcus neoformans. C. neoformans is in immunosuppressed patients. In theseen in vivo as the yeast form surrounded normal host, pulmonary cryptococcosisisby a thick capsule.The hyphalsexual from most often a subclinical infection. When,is Filobasidiella neoformans. The clinically or roentgenologically evident, ituncollapsed round yeasts are usually from usually presents as a primary hilar lymph6-7 um in diameter. Single buddin_ yeastswithnarrownecksmay also be seen',node complex which mayspontaneouslyor remain dormant6,resolveIts distinct feature is its Pulmonary cryptococcosismay alsopolysaccharide capsule which is cause productionof only scant, sometimesdemonstrated as a halo by India ink or blood-streakedsputum. The x-ray findingsmucicarmine in slide preparations. The usually consist of multiple subpleuralcapsule is a majorvirulencefactor because nodules with or without hilar adenopathy,it may be immunosuppressive,any impair unilateralof bilateral alveolar or interstitialleukocyte migration and may activate the infiltrates, circumscribed mass lesions,alternative complement pathway in serum, abscesses with fluid levels or cavitaryOne role of the capsule in pathogenesis lesions, and unilateral or bilateral pleuraldepends on its antiphagocytic properties; effusions6.the efficiency of phagocytosis of anorganism by macrophages is inversely to From the lungs, there is silentthe size of the capsule5,hematogenous spread to the brain, whereclusters of cryptococci collect in theDifferential diagnosis at this stage periascular areas of cortical gray matter andinclude the various deep fungi. _lasma basal ganglia since the organism isca_sulatum, sDorothrix schenkii, and neutropic. In fact, majority of patients havePneumocvstis carinni all do not possess the meningoencephalitis at the time ofcapsule characteristic of CrvPtococcu.s.. diagnosis. Early signs and symptomsFurthermore, H. oapsu/atum is smaller and include headache, nausea, staggering gait,usually intracellular. S. schenkii is usually dementia, irritability,confusionand blurredfootball-shaped,while P. carinii is usually vision2. There is no clinical evidence toboat-shaped. On the other hand, considerthis in our patient.There is usuallyBlastomyces dermatitides also possessesa no lyrnphadenopathyand no oral mucosalcapsule but is distinguished by a wider lesions.buddingisthmus1.Cryptococcosismay involveseveralThe cryptococcal organism has other sites outside the CNS and lungs.been isolatedfrom dried pigeondroppings Singleor multipleskinlesionsmay be foundand nesting places an this associationhas in about 10 percent of patients. Bonebeen described since the 1950's by lesions resembling tuberculous coldEmmons. Pigeonsdo not rid their nests of abscesses are also found in about 5-10excreta unlike other birds1. They excrete percent.Other rarer forms of cryptococcosisinfective cryptococci without themselves includechorio-retinitis,adrenal involvement,being affected. Healthy persons with a myocarditis, endocarditis, peri-carditis,historyof heavyexposureto pigeonshave a esophagitis, hepatitis, peritonitis, arthritis,much higher rate of positive delayed skin bursitis, myositis, renal abscess andtests to cryptococcal antigen or pr°statitis4crypt°c°ccin4 Current trends of managementThere is good evidence to assume preferred I combination therapy ofair-borne mode of transmission of amphoterecin-Bwith Flucytocine.aerosolizeddroppings,enteringman via therespiratory tract. Respiratory involvement

THE CASE OF THE CREEPING CRYPT*FREDERICK Y. HAWSON, M.D.**GIL M. VICENTE, M.D.***ABSTRACTThis is a case report involving a 49 year old female with a chief complaint of right lateralneck mass with a history of chronic non-productive cough and exposure to pigeon droppings.Flexible endoscopy revealed masses in the nasopharynx and the right trachea-bronchialjunction. CT scan showed a right pre- and para-vertebral Ioculated cystic mass extending fromthe nasopharynx to the oropharynx biopsy of which revealed Cryptococcal infection. Thisunusual feature is made the more significant in that it occurred in a non-immuno compromisedpatient and lends more concrete evidence as to the lymphatic spread of cryptococcal infection.This is probably the first case of cryptococcosis with such unusual manifestations in bothlocal and international literature. Awareness of this should help in the early recognition andmanagement of the disease.Keywords: Lateral neck mass, cystic mass in the nasopharynx, cryptococcosis, lymphatic spreadINTRODUCTIONOf the challenges faced by an condition initially manifesting as a one-sidedOtolaryngologist-Head & Neck Surgeon, few lateral neck mass, with other uniqueconditions can be as challenging in terms of features. It is also the aim of this report todiagnosis and management as a one-sided provide sound explanations to account forlateral neck mass. The possible differential such features, especially in the aspect ofdiagnoses are simply too numerous. In how this condition spread the way it did ingeneral terms, this mass may be neoplastic, this casecongenital/development or inflammatory innature. But from there, the field is wideThe significance lies in its accountopen, If one thinks of neoplasm, the of an unforeseen condition with anpossibilitieswould be the parotidgland as a interesting presentation and course ofprimarysourceof the tumor,a lymphomaor disease development. This report will alerta metastatic lymph node. If the Otolaryngologist-Head& Neck Surgeoncongenital/development masses, then to the existenceof such a condition,therebylymphagiomas or branchial cysts are the adding to one's knowledge of possiblemore common ones_ When considering differentialsof a lateral neck mass. There isinflammatory conditions, it may be an further significancein its contentionthat theadenitis or sialadenitis, bacterial, viral or diagnosisof this patient's neck mass is thegranulomatous,first documentedin local, or probably eveninternational,scientificliterature_However, aside from theaforementioned first considerations theoccasionalrare surprisediagnosisshouldbeCASE REPORTborneinmind. The objectiveof the followingcase presentationis to describe and makeThe patient is ZB, a 49 year old,the Otolaryngologist-Head& Neck Surgeon female, married, housewife from Metroaware of suchdiagnosisof an unexpected Manila. On May 1994, a non-tender, non-"Presented,PSO-ClinicalCaseReportContestApril 7m 1995,SubicInternationalHotel,OlongapoCity**Resident,Departmentof Otorhinolaryngology, St. Luke'sMedicalCenter***Consultant,Departmentof Otorhinolaryngology, St,Luke'sMedicalCenter

REFERENCES1, Blitzer,A and W. Lawson, ads. Fungal Infectionsof theHead and Neck. The Otolaryngologicclinics of NorthAmerica1993; 26(6).2. Isee|bache¢, et al. Harrison's Principles of InternalMedicine 131hed New York:McGraw-Hill,1994.3. Jawetz, E. Review of Medical Microbiology17th ed., Norwalk:AppletonLange,1987.I4. Mendell, GI, at al ads. Principles and Practice ofInfectiousDiseases 3rd ed. vol Iii. New York: ChurohillLivingstone,1990.5. Vartivarian.SEet al. Regulationof Cn/ptococcalCapsularPolyrsaccharidebyIron.The Journalof InfectiousDisease1993; 167(1): 186-190.6. Wasser, L andW Tatavera.PulmonaryCryptseocccaisinAIDS. Chest 1987;92940: 692-694.

THE CASE OF THE MISSING DENTURES*EDGAR ANTHONY Q. DELFIN, MD**EMMANUEL S. SAMSON, MD***ABSTRACTThis paper reports a case of 27 year oldformer medical student who had recurrent boutsof fever and productive cough of 1 year duration necessitating endotracheal intubation_ Chest x-ray revealed a denture consisting of 4 teeth and 2 metal hooks at C4-C5. An endoscopic attemptto remove the foreign body failed but an esophagotomy via a lateral pharyngotomy approachproved successful. The patient apparently swallowed the denture while under the influence ofmethamphetamine hydrochloride (shabu).Key words: Missing denture, methamphetamine hydrochloride (shabu),lateral pharyngotomy approach,INTRODUCTIONfor which amoxicillin 500mg TID was takenMethamphetamine hydrochloride or with alleged improvement. Case closed, or"shabu" in local parlance is well known for so it seemed.the feelings of fearlessness and well beingbordering on near-fatal foolhardiness that it One month before admission, theinduces. People high on it can stay awake patient developed mild dyspnea associatedfor dayswithoutfeeling tired and drowsy, or with productive cough and consulted acan sleep in total bliss. This case will not physician who diagnosed it as recurrentattempt to highlight the pharmacology and tonsillitis. Not satisfied, the patient consultedmedico legal aspect of methamphetamine, an ENT specialist who did flexibleInstead, an unusual complication which can esophagoscopy, diagnosed it as esophagealbe attributed directly or indirectly to its ulcer, and gave amoxicillin which affordedeffects will be discussed,relief.Three days before admission, theCASE REPORT patient developed on and off fever and afew hours before admission, suddenR. D., a 27 year old male, former dyspnea for which the patient was rushed tomedical student, is a self-confessed shabu a government hospital where an impressionuser. One year before admission, while of bronchial asthma was given. Furtheremerging from the effects of shabu taken deterioration of breathing prompted referralthe night before, the patient noted that his to this institution. He presented at thedenture was missing and assumed that it emergency room as a fairly developed malewas taken out the night before and placed who was conscious but agitated, coherentaside somewhere. A thorough search and in severe respiratory distress_ Thereproved futile and a new set was ordered were multiple linear scars over the abdomenfrom the dentist the following day. Except and forearms. The anterior neck was slightlyfor the slight pain and vague feeling of lump bulging, more to the left, and tender. Cheston the throat, the patient had no other examination revealed crackles and wheezessymptoms and attributed it to an infection all over the lung fields. The impression---acute respiratory failure, etiology unknown."Presented, PSOHNS Clinical Case Report Contest, Mid-year ConventionApril 7, 1995, Subic International Hotel, Olongapo City**Resident, Department of Otorhinolaryngology, Manila Central University HospitaI-FDMTF***Consultant, Department of Otorhinolaryngology, Manila Central University HospitaI-FDTMF

Further insertion exposed the denture withPatient was immediately intubated the metal hook as the presenting end,and was relieved. The white blood cell count enveloped by granulation tissue. Thewas 15.8 x 10/L; electrocardiogram was presenting metal hook was grasped with anormal. Arterial blood gas studies showed a forward grasping forceps and with a firm butcompensated metabolic alkalosis and gentle traction and manipulation, extractionovercorrected hypoxemia. Chest and was attempted. However, the denturecervical radiographs showed a set of remained fixed and immobile.dentures consisting of 4 teeth and 2 metalhooks, located at C4-C5, surrounded by softtissue swelling. It was then that the patient The team swung to plan B and,was finally referred to ENT for proper using the light at the end of the scope as amanagement, guide, a left vertical incision was made_i!iiiiiiiiiiiiiiiiiiiiiii__i anterior to the sternocleidomastoid muscle,; '%i::i::;:;iii::iiiiiiii;_:' ! which was deepened down via blunt:: dissection until the esophageal wall wasreached. A 1.5 longitudinal incision wasThe denture was finally extricated and thegranulation tissues were removed. Furtheri made on the esophageal wall and through it.__ inspection of the esophagus showed_ .:_i_i_i_::_i_i!. _ abscess was noted on the adjacent areas. Anasogastric tube (NGT) was placed and theesophageal incision was closed usingBii_ii i absence chromic 4-0. of perforation. Likewise, nowas brought After tobeing the operating stabilized, room the with patient aninitial plan to remove it endoscopically and _;:_;_:;:_:;;;_:;_i_;_;_i_:_;_;;_;_;_;_the option to do an esophagotomy via alateral pharyngotomy approach ifendoscopic removal fails.OPERATIVE TECHNIQUE: ii!i;i!iiii!i_;!ii_ii_;;:!i_ii_!_i:i_ii!_i_::_i_i_i_i_iiiiiiiiiii_iiiiiiiiiiiiiiiiiiiiiiiiiiii.-. : , ,.,,],..,:_: • .. ... , ,• :............:_,._,_i!',!:i:: " " • :. " ' :• . .. •.. -.;:::: ,• . . ..... , , , .-_.:-: '.. .."i:. ::i,' _'.._.:_:._i_:!:. ,._:..,... -.-...:.:+,' ._ . :::::"::.::i:_:_::•.i i ,:, :::::::!::_:i:i:_::: •VERTIOALINCISIONANTERIORTO : ?:::_::_?: ,•:;,., ....::.:...STEIINOMASTOIB M. " .:::".i..i: :i::::i- Under endotracheal anesthesia, a .... .... ........ ........ ::40x10 rigid esophagoscope was insertedperorally and into the lumen of theesophagus, At the C4 level, the lumen wasseverely narrowed by edematous mucosa.

............................::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::_............................................";;:":".......................... '.possibilityis oneof the commonestcause ofits oversight.::::::::::::::::::::::::::::::::::::::::::::::::: .:i:::::::::::::::::::::::',:,.%_,_: _ =========================================================. .;:_,:,_ :::2 :::..... .:;::_ :::;:.::".:: =======================., •_:_:_:_:_:,:_ii:i:.!_._._:::.::::::::::::::_:::_::--¢- _,:,_: "::::_,;::.=============================:.......................;:::;:;:;:_::.,.;.:::i;i,;::i'. =====================::... 'But how coulda 27 year old former,::_ .... ::_:_:_:_:_:_:_-_:_i_:_::_........... medical student miss a positive history of:_:_:_,_:_',_:_: ::_:_:: ::.:.:::::::::::: :::::_'_::_;_,_; :.:::i, ::;_::_.. _._ .... ::::::::::::::::::::: ............... _::::_:_.::::_:_:_:_:..:.:......... ingestion?Furthermore,what made several::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::_:::::::::::::::::::physiciansand even a specialist on that.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::field missit out completely?In this patient,_:_:_:_:;:;:;:_:_:_:_:_:;:;:_:_:::_=;:_:_:;:_:_:_:_:_:_::;:_;=_=;;:_:_;_;:;;_::_;_;_;_=_;_:_;::_::;_:::_:_`_===_===severalfactorscame to play:Postoperatively, the patient was 1. it occurred during sleep, a timeplaced on massive antibiotics. NGT was when the patient's normalretainedfor twoweeks. Patient was protectivemechanisms,like thecoughreflex, andgagging,weredischargedasymptomaticand happy,weak;2. the recumbent positionfavoredDISCUSSION a dislodgment into thehypopharynx and eventuallyA foreign body is an object or intothe esophagus;substanceforeignto the locationwhere it is 3. possibly, a loosening of thenormally found. There are two general denturefrom its attachment;classes, namely: exogenous, substances 4. absence of recollection offrom outsidethe body like dentures, coins,patient's activitiesthe previouschunks of meat, etc.; and endogenous, night, includingwhether or notthose from within like a disimpacted tooth,dentureswere removed priortosleep, owing to perhaps theetc.effects of shabu.At the PhilippineGeneral Hospital, 5. absence of definite signs anda five-year review by Jamir, Tuazon, et alsymptomsof a foreign body.(1989) showedthat among adult Filipinos,dentures is the most common cause of What happens when a foreign bodyesophageal foreign bodies (26%), followed remains unrecognized and stays in theby chicken bones and meat chunks. Among esophagus for a long duration?children, coin is the most common, followedby plastic capsand pins.A foreign body, especially as largeand hard as a four-toothed, two-hookedOrdinarily, diagnosisof the foreign denture may elicit an inflammatorybody in adults does not pose any difficulty response around it, followed by infection,owingto the presenceof a positivehistory, and ultimately, perforation. If the foreignThis is so even in the absence of obvious body is located in the lower esophagus,signs and symptomslike dysphagia, chest mediastinal emphysema or abscess maypain, regurgitation,and the presenceof the follow a perforation, manifesting as highobjects in the radiographs. In children, fever, tachcycardiaandretrosternalpain.however, diagnosis is rendered difficult If it is located higher up, anteriorespecially in the absence of clinical and perforation into the trachea will causeradiographicsignsand almostimpossibleinthe absence of witnesses to the actualrespiratorysymptomsthat can be mistakenfor a primary pulmonary condition.ingestion or circumstantialevidence (e.g., However, mere compression of anteriorviolent coughingwhile playing with small wall, even inthe absenceof perforation,canobjects, droolingwith refusalto be fed; etc). be equally misleading because it canIt is a widely acceptedfact thatthe failureto impinge on the tracheal lumen. Spread ofrecognizethe presence of foreign body is infection/ inflammation to either side maydue not so much to inabilityto make the irritatethe recurrentlaryngealnerve causingdiagnosis as to failure to attach sufficient hoarsenessandlaryngealsymptoms.importantconsiderationto foreignbody as adiagnosticpossibility.In otherwords, failureThese explain the development ofto considera foreign body as a diagnostic complications variously diagnosed as

Dronchial asthma, pneumonia, tonsillitis anaBIBLIOGRAPHYacute respiratory failure. In the absence ofan incriminating history of foreign body 1. Chong-teck Lira. A prospective study ofingestion, the most rational clinician wouldforeign bodies in Singapore. Archives ofbe led astray. Otolaryngology Head & Neck Surgery.Jan 1994; vol 120:pp 96-101.The lateral pharyngotomy incision 2. Liancai Mu et al: The cause andwas deemed necessary to extract the complications of late diagnosis offoreign body owing to a failure of foreign body in the esophagus. Archivesesophagoscopy, Furthermore, it enabled a of Otolaryngology Head & Neckbetter inspection of the status of the Surgery. Aug 1991. vol 117: pp 876-esophageal wall and its surrounding 879.structures which rigid esophagoscopy would 3. Giordano A. et al: Current managementnot permit. Fortunately, neither an abscess of esophageal foreign bodies. Archivesnor perforation was present, of Otolaryngology Head & NeckSurgery. Apr 1991. vol 107: pp 249-251.4. Jackson and Jackson:CONCLUSION Bronchoesophagology. May 1950.5. Caparas et al: Basic Otolaryngology.It must be emphasized that a 1993;pp193-197.prolonged sojourn of a foreign body, 6. Gates. Current therapy inwhether this be from the airway or food otolaryngology head and neck surgery.passage, will eventually lead to 5th edition; 1994. pp 487-488.complications and death. There are very 7. Mangal BD. Retrieval of foreign bodyfew reported cases of long-retained from upper GI tract by flexibleesophageal foreign bodies. Interestingly, the endoscope - an experience. Journal oflongest sojourn reported was that of a the Association of Physician of India. 41woman who swallowed a wooden button (1) 11-3, Jan. 1993.when she was eight years old, but only 8. Willsher PC. et al: Denture = Difficultmanifested symptoms 18 years later. That esophageal foreign bodies. Australianwas definitely an exceptional case because and New Zealand Journal of Surgery.these patients usually do not survive for 6 Sept. 1993, pp 736-738.years from the time of ingestion, and usually 9. Webbs, P. Management of upperdie within a year. gastrointestinal tract, foreign bodies.Annals of Surgery. Feb 1986. vol 21. ppThis patient survived for almost a 741-746.year but barely, no thanks to the clouded 10. Canno!ly, AA et al. Ingested foreignrecollections induced by intake of shabu, bodies: Patient-guided localization is auseful clinical tool. ClinicalOtolaryngology. Dec. 1992. 17(6): pp5O2-524.

:: :::expefien:ced:: obstructive Sy_p_omS only :i : :::: _i_e _Si:ee:Pi:: :::Given_h:eSloWly: growing :i i;e:ti_opha_ngeai:: mass : pi:ogressiveiy: i :J i ........e air passages :: :v:eioo tyl idi:ow (the:: ventL_,ii:il effect);: : :" tiV:e pressures ::near tl]e:_: :: tubercuous: ul:: origin; :the lesion .... :,: :: : metastasis::: i::noted: in : the :........... ateral _ku}} ....... :Xra -Y ..... also S_gcested - a ........:3 growth 0I m::asswe with this:size::,, Of: : : :re:suts: fo:te:head: and:[ m_,[_tspecific,:: : :iio[ed: ::necrot : : :

malignant process,samplingerrors often ledBIBLIOGRAPHYto misseddiagnosis. In a study by Lee andco-workers, FNAB definitively diagnosed 1. Paje-Villar et al: Tuberculosisin Infancytuberculosisin only 62% of cases. In our and Childhood. Task Force onpatient, only the repeat FNAB of the Tuberculosls-Philippine Pediatricassociated masses yielded the Society, 1993.pathognomoni caseationnecrosis. 2. Cummings, Charles et al:Otolaryngology-Headand Neck SurgeryThe detection of acid fast bacilli Second Edition; Mosby Yearbook,(AFB) still remains as the most reliableBoston,vo12: pp.13_°7-98.evidencefor TB. In ourcase, demonstration 3. Ejercito, Victor: Snoring and Sleepof the bacilliin the cheesy materialdrainedApnea Surgery; Symposium on Sleepfrom the abscess clinched the diagnosis Apnea, UP-PGH Medical Center, Mar,despite the negativesputumand urineAFB 1995.stains, chestX-ray and final histopathologic 4. Robbins,Stanley et al: PathologicBasisreport.The positiveMantouxtest confirmedof Disease-thirdedition; WB Saunderspast exposure to TB, possibly from herCom., Philadelphia,1984pp.14-15.partiallytraated father. 5. Personal Communication:A. Dimacali,MD, J Avila, MD, and C. Lim, MD;The case presented stresses the Pathologists-Department of Pathologyneed for vigilance in a child who snores.UP-PGH MedicalCenter.The snoringpatientshouldundergoat least 6. Paparella,Michaelet al: Otolaryngology,a thorough physical examination and 1991, WB Saunders, Philadelphia,appropriate radiologicstudies in order toChapter42.determinethe presenceandcausesof OSA. 7. Steinkamp, J of Otol. Aug. 1993.A diagnosismade early in the courseof theAbstract.disease may render the illness still 8. Glasier et al: CT and Ultrasoundamenable to medical therapy and preventImaging of Retro-pharygealAbscess inemergencysurgicalinterventions. Children; AJNR-ASN-J-Neuroradiol;July-Aug1992; 13 (4):1191-5.9. Lee KC et al: ContemporaryCONCLUSIONManagement of Cervical Tuber-culosis;Laryngoscope,Jan 1992; 102: 60-64.Tuberculosis,the fifth leading cause 10. MEDLINE search from 1989 to 1995.of morbidityand the fourth leading causeofmortality in the Philippines, may presentwith an unusual spread to theretropharyngeal space. The subsequentnarrowing of the airway and normalphysiologic changes experienced duringsleep may cause obstructive sleep apnea,especiallyin children.Snoring,found in92%of cases of OSA should, therefore, not beignored. It indeed can be deemed as anominoussignof a potentiallylife-threateningyet increasinglyprevalentdisease,

THE OPENED CAN TECHNIQUE A NEW METHOD OFTRACHEOSTOMAL CONSTRUCTIONIN TOTAL LARYNGECTOMY*ANTONIO H. CHUA, M.D.***WILLIAM U. BILLONES, M.D.**GIL M. VlCENTE, M.D.***JERRY AB. ROSARIO, M.D.**ABSTRACTThe paper is an innovativecase reportthat presentsa new techniqueof tracheostomalreconstructionin total laryngectomy done in a tertiary government hospital involving threepatients.This newtechnique revealed no evidenceof stomal stenosisafter a longterm followupranging20-26 monthspost-operatively.The technique,basedon soundsurgicalprinciples,basicbiophysicaldynamics and simple in design has the following salient features: a) creation of twoobtuse angles at the cartilage-muscle junction b) creation of a cuff of posterior membranous wallc) anchorage of posterior membranous wall to superior skin flap d) anchorage of anteriorcartilagouswall to inferior skin flap e) horizontal circulation of the stump orifice.Keywords : Tracheostomal Reconstruction, Total LaryngectomyINTRODUCTIONprolonged use of a laryngectomytube ", andthusencountereda stenosisrate of 42%.4Tracheosmal construction is anintegralpart of total laryngectomy.However,The consequencesof tracheostomaldespite the wide experience and variability stenosis are wide ranging in nature andof techniques available on this procedure, severity, contributing significantly to bothstenosisof the tracheostomastill occursas psychosocial and physical morbJlityin thea distressingpostoperativecomplication1 -- laryngectomee.Optimum air exchange andspoilingan otherwisesuccessfulresectionof ability to clear tracheobronchial secretionsthe primary laryngealpathology,may be compromised.Stagnation of mucusdue to impaired mucociliarytransport is aStenosis of the tracheostome may potencial factor in recurrent pulmonarypresentitselfinthe immediatepostoperative infections. Occasionally, some patientsperiod or years later. Its incidence is as may need to wear a tracheostomy tube orvaried as the number of authors definingit, button to keep the tracheostoma patent,ranging from a low 4% to a high 42%. usuallyfor24 hours a day.Loewyand Laker reported only six vaguelydefined " benignstomal strictures" in theirWith these complications, patientsseries of 138 cases;. Langenbrunnerand may require another trip to the operatingChandler, who defined an "inadequate roomfor tracheostomalrevisionprocedures,stoma" as one that required a tube at which, in addition to being a financial andanytimeafter the operationor the revision, psychological5burden, are not alwaysreported stomal stenosisin 43 of their 124 successful. This failure may be attributablepatients (34%)3. Less clear was the to the presence of excessive scar tissues,definition of Yonkers and Mercurio, taking shorttrachealstump, and the persistenceofinto account "symptomspreventing normal the original factors which have led to thedaily activities or necessitating the occurrenceof the stenosisir, thefirst place.5"l®t Place, PSO-HNS Surgical Case Report Contest, Mid-year ConventionApril 8, 1995, Subic International Hotel, Olongapo City**Resident, Department of Otorhinolaryngology, Jose R. Reyes Memorial Medical Center***Consultant, Department of Otorhinolaryngology, Jose R. Reyes Memorial Medical Center

Notwithstanding the differentincidences of stenosis reported in the Two tracheal cartilage incompleteliterature, there is definitely a need to rings are excised, taking care to spare theaddress this problem which would require posterior membranous wall (FIGURE 1).prolonged care and long term follow-up. It is The incision is made immediately superiorprudent for the Head and Neck surgeon to to the planned remaining tracheal stumpbe cognizant of this complication and utilize without exposing the perichodrium, anda simple and effective technique that can extends obliquely cephalad as it nears theprovide an adequate tracheostome. One posterior tips of the cartilage half-ring. Th_isobviously can ill-afford even one occurrence cut produces an obtuse angle along bothin one's series of laryngectomies, cartilage-muscle junctions of the trachealconsidering the distress this condition ring and serves to break up an otherwiseimposes on the patient and surgeon, concentric suture line (FIGURE 2). Thetotal result is the construction of a trachealPrevention is still the ideal method stump with at least a 1.5 cm cuff of posteriorin dealing with this problem6. Preventive membranous wall, which bears uncannymeasures include careful preoperative resemblance to an opened tin can.planning, meticulous surgical technique anddiligent postoperative care. The best time to._.,_deal with tracheostomal stenosis is, .,-' ./ _,,_:_._-. _-_,:_,therefore, laryngectomy. right during the initial :: :,_.._..... :..-_-;-;_ _:._.,"_,k_'_,,_-.x,' ' -.,_ ._ :'_Various techniques have been _:., .....described for this purpose. The more _ _tthe tracheal stump, a variety of complex __commonly flap designs utilized and insertion ones include of implantation beveling of_tdevises -- each offering its own advantages _: ._as well as disadvantages.The authors shared their experienceon a new technique of tracheostomalconstruction based on sound surgicalFigure1simplicity of design. A representative case _ :is illustrated to demonstrate the "_-......,, .,_ ,_"•.......;_.._-;.._+.:_;-_-effectiveness of this method. =_ .,_' ,-_......_,:_;_ : .., _> ,..::._,_::.._principles, biophysical dynamics and _._... _TECHNIQUE:; _.,..;_,,;.;-A standardtotal laryngectomyvia aU-shaped apron flap is done, preceded by a Figure 2radical neck dissection. Clean surgicalmarginsare ensured by providinga 1.0 toRedundant apron flap skin is1.5 cm clearance from gross tumor edge. excised to provide an ellipticalskin stomalFresh frozen section is done if there aredoubts regarding the margins,edge. Any excess adipose tissue is exciseddeep to the skin flap edges. The trachealAs a tracheostomy prior to the cartilage incomplete ring is slightly splayeddefinitive surgery had been done, an laterally and suture to the inferior skin flapadditional tracheal cartilage incomplete ring under mild tension. Modified verticalinferior to tracheostomy incision is removed, mattress using 2-0 silk is done, traversingThe stump is reinspected to ensure that it is the skin (peripherally), cartilage(extramucosally), then skin (medially). Thegrossly free of tumor and inflammedsuperior flap is attached to the membranoustissues, tracheal wall with mild stretching of the

_:::_::::'_:_!iif!i( ¸:¸: :!!:ii! !:::: !:i: _i::/:i:/::::!...." /"_ :_:;:>;::i_(_://:i//_::_i_;:/_:/_:_'_'_:_:i:_ " -_

it vulnerable to concentric scarring in the What is needed perhaps isfuture,something that is less complex with lessincisions and manipulation.A variety of techniques employingZ-plasty, double V and V-Y flap designs of The technique described hereinprimary tracheostomal construction had offers the advantages of the believed andbeen utilized at the time of the the flap techniques as well as simplicity oflaryngectomy in order to prevent stenosis by design. The primary objectives in theenlarging the stoma and redirecting the surgical prevention of tracheostomalforces of scar contraction, stenosis are achieved, namely: carefulapproximation of skin and mucusA butterfly or bowtie stoma had membrane, elimination of extensivebeen developed by Clairmont by excising compressive forces, active tension on theinferiorly based triangles from the anterior stomal margins, increased circumferenceand posterior tracheal stump. Superior and and redistribution of the force of sca,rinferior skin flaps, created by lateral skin contractions and prevention of undueexcisions, are inset into the apex of the exposure of tracheal cartilage.tracheal defects.TBy simply incorporating theTrail et al used a method of double posterior membranous trachea to the stump,rotation flap Z-plasty utilizing the skin the anteroposterior diameter of theposterior to the stoma transposed into an tracheostoma is increased, simulating aoblique incision in the posterior beveled stump. But unlike the lattermembranous tracheal wall. A small flap of procedure, resection of tracheal cartilagesmucosa of posterior tracheal wall is then start from the inflamed tracheostomy sitetransposed into the tumor site of the skin while preserving the posterior wall. This, inflap.8 effect, spares more normal trachealsegments in increasing the stomal diameter.Isshiki and Tanabe utilize superiorly in addition, there is no exposure of trachealbased double skin flaps, created by a Y- cartilage that may lead to perichondritisshaped cutaneous incision, each of which is (FIGURE 4).inserted into a separate oblique incision ofthe posterior tracheal wall.9 .3,......... ._ _. j_Hartwell and Dykes created a :_, ..._.:.---.,excising a wedge of skin on each side of _ ....,this flap, The flap is advanced and inset into ..... _'_:_" "triangulara vertical incisionposterior-superiorof the posteriorskintrachea.1°flap by ......-;_,:_:,..__ _,,_;':ii'..These flap designs generally.,...;,., . ....utilized the same basic principle of stomal Figure 4enlargement and inhibition of circularscarring where the flaps break up the Compressive forces around theconcetric circle of the stoma. Although stoma are reduced by extensive removal ofeach had been reported to have favorable subcutaneous fat, excision of redundantresults by their authors, these techniques skin and splaying the trachea _thare needlessly complex in design.6 anchorage of the cartilaginous portion onAdditional incisions along the trachea and the inferior skin flap. This provides activeperitracheostomal area would theoretically tension on the stomal margins and furtherresult in more scarring due to additional dilates the stomal aperture.manipulation. Again, cutting through thetracheal cartilage is inherent in the designwhich may complicate the results,Since the stump orifice is orientedalmost horizontally and assumes a morenormal anatomical position, less tension isgenerated on the stump by the pull of thepulmonary ligaments caudally as compared

to other techniqueswhere the aperture hadThis technique offers the distinctto be positionedverticallyto anchorit on the advantage of making a trouble-free stomaskin flaps. With less caudal pull, there is by observing the following surgicalless tendency for the stoma to close and principles:carefulapproximationof skinandstenose(FIGURE 3).mucusmembrane, eliminationof extensivecompressiveforces, active tension on thePerhapsthe most importantfeature stomal margins, increased circumferenceof this technique is the inclusion of the and redistdbutionof the forces of the scarposterior membranous portion in the contractions and prevention of undueotherwise circular stump, thereby breakingthe concentric circle of the futureexposure of tracheal cartilage,tracheostoma. This is the basic principle The three patients on whom thisutilized in the flap techniques. Incorporating technique was employed showed nothe trachealis muscle indirectly creates an evidence of stomal stenosis as of lastobtuse tdangl,e on the junction of the follow-up (20-26 months post-operatively).cartilageand muscle on both sides similar A forthcoming prospective comparativeto inserting bilateral triangularflaps on the studywill be reportedinthe nearfuture.stump(FIGURE 2).This redistributesthe forces of scarBIBLIOGRAPHYcontraction which eventually preventsnarrowing by scar contraction which 1. Kuo, Michael et al. Tracheoetomal Stenosis Aftereventuallypreventsnarrowingby scartissueLaryngectomy,An analysisof PredisposingClinicalin the future.Factors. Laryngoscope, 104:59-63, 1994.2. Loewy, A. and Laker, H Tracheal Stomal Problems.Arch Otolaryngology,87:51,1968.Finally, with less incision lines and 3. Langenbrunner,DJ and Chandler, JR. Trachealtissue manipulation, postoperative care is Stenosis: Causes and Correction. South Medicaleasier with minimal crust formation andJournal, 61:838-842,1968.faster woundhealingtime. 4. Yonkers,Stenosis FollowingAj andTotalMercurioLaryngectomy.GA TracheostomalOtolaryngolClinics of North America, 16:391-405, 1983.5. Wei, Wi etal. Tracheostome Construction DuringSUMMARY AND CONCLUSION Laryngectomy. A Method to Prevent Stenosis.Laryngoscope 93:212-215, 1983.6. Myers, EN et al. Tracheal Stenosis Following TotalIn summary, a new method of Laryngectomy. Annals of Otol Rhinol Laryngolstomal construction called the OPENED 91:450-453,1982.CAN TECHNIQUE is presented. Basically, 7. ClairmontA. TracheostomaConstructionduringLaryngectomy: Techniques to Prevent Stenosis.its salient features are the following:Journal LaryngolOtol 92:72-75,1978.8. Trail M et al. Z-Plasty of Tracheal Stoma at1. creation of two obtuse angles at the Laryngectomy.Achievesof Otolaryngol88:110-112,cartilage-muscle junction to break the 1968.concentricsuture line 9. Isshiki N and Tanabe, M. A simple Technique toPrevent Stenosis of the Tracheostoma After Total2. creation of a cuff of posterior Laryngectomy. Journal of Laryngol Otol 94:637-642,membranous wall 1980.3. 3. anchorage of posterior membranous lO. Hartwell SW and Dykes ER. Construction and Carewall to superior skin flap of the EndTracheostomy. AmericanJournalofSurgery, 113:498-500, 1967.4. anchorage of anterior cartilaginous wall 11. Cummings, CW et al. Otolaryngology-Head andto inferior skin flap Neck Surgery, Vol 3, Baltimore, Mosby Yearbook,5. no additional incisions that might 1993.unnecessarilyexpose catilage 12. Bailey, BJ and Biller Hr. Surgery of the Larynx,Philadelphia, WB Saunders Co., 1990.6. horizontal orientation of the stump 13. McArthy, JG Plastic Surgery Hr. Surgery,orifice Philadelphia, WB Saundera Co., 1990.CurrentTheraphy7. 7, no complex flap design that requires 14. Luce, EA. Laryngeal Carcinoma:extra care during manipulation and in Plastic and Reconstructive Surgery. Philadelphia,suturing Bc Decker Inc. 1989.

THE USE OF FULL THICKNESS CALVARIAL BONEGRAFTING IN FACIAL RECONSTRUCTION*FELIX P. NOLASCO, M.D.***ROMULUS A. INSTRELLA, M.D.**MA. TERESITA R. VILLA-REAL, M.D.**ARNEL RICO ALVIS, M.D.**ABSTRACTThis is the case of a 42 year old male who sustained severe maxillofacial trauma afollowing vehicular accident. The patient sustained multiple comminuted facial fractures. Thefractures involved the right lateral orbital wall, medial orbital rim, zygomatic bone, anterolateralmaxillary walls and alveolar ddge. Initial open reduction with Internal fixation revealed massivebone loss. This study used a full thickness calvarial graft as source of bone replacement formassive bone loss. The different surgical accesses were the coronal infraorbital rim andgingivobuccal incisions. The advantages of calvadal graft over rib and iliac bone were discussed.Post-operatively, there were no complications and the patient had a more satisfactory andsymmetrical face but may still need secondary soft tissue reconstruction for aesthetic purposes.Keywords: Full thickness calvadal bone graft; multiple comminuted facial fracture; facialreconstruction.INTRODUCTIONThe treatment of old facial bone massive lossof facial bones. In this case, afractures has always been a very full thickness calvarial bone graft whichdemanding and, oftentimes, frustrating adequately replaced the large amount ofendeavor. More often than not, the bony loss was tried_fractured or displaced bony fragments hasbeen resorbed due to plain neglect or Other innovations in theinadequate management. When a management of maxillofacial trauma whichsignificant part of the facial bones is lost, the were employed in this case to complementoriginal appearance of the face is altered or the use of the full thickness calvadal graftinglost as well, Reconstruction or returning the were:contour of the once admired face is then abig challenge to every otolaryngologist in 1. Three dimensional (3D) CT scan whichthis particularfield of interest,has revolutionized the diagnosis of facialfractures by accurately detailing the fractureRecent advances in diagnostic as lines, the degree of displacement of thewell as the therapeutic management of fractured fragments and the amount of bonemaxillofacial trauma have rationalized and loss;improved treatment approach. Among these 2. Extended surgical accesses and internaladvances, the extensive use of immediate or approaches which allowed wider exposuresdelayed bone grafting, especially the use of of the entire facial skeleton while minimizingsplit thickness calvadal grafting is becoming external incisions and unsightly scars;very popular because of its advantages over 3. Internal rigid fixation with titanium platingthe lilac and db graft. However, the amount system which provided accelerated boneand thickness of this graft is sometimes not healing and functional immobilization of theenough in reconstructing defects withfractured or grafted bones."4thPlace, PSO-HNS Surgical Case Report ContestApril 8, 1995, Subic International Hotel, Olongapo City**Resident, Department of Otorhinolaryngology, East Avenue Medical Center***Consultant, Department of Otorhinolaryngology, East Avenue Medical Center

Two years later, the patient cameOBJECTIVE back to this institution with still anunsatisfactoryface. Bone losswas evident,The objectivesof this paper is to most especiallyat the malar area, alveolarpresentthe experience of this institutionin ridge and infraorbitalarea. The right lid hadthe innovative surgical management of a inadequateclosure,and globe displacementpatientwith extensive bone losssecondary was still evident. The patient had facialto multiplefacial fractures after failed open asymmetryand a severely flattened malarreductionusingfull thicknesscalvarialbone area and a very pushedback right alveolargraftingandto evaluatethe difficultyandrisk ridge. A 3D CT scan was clone revealingof the procedure as well as the large bony and soft tissue defects in thepsychologicaland economicconsiderations region where the right malar/ maxillaryinvolved, fractures have been. There were smallmetallicfragments in the region of the rightCASE REPORTmandibularramus and posteriorto the rightalveolarridge. Small bonyfragmentswereThis is a case of E.M., a 42 year old also noted in the right infratemporalfossa;male soldier who 6ustained multiplefacial the left maxillaryand the rightfrontal sinusfractures when his jeep suddenly swerved were congested/fluidfilled. Old temporaland fell into a ravine. Patient was initially bone fractureswere noted. The visualizedbroughtto Baguio General Hospital where brainstructuresappeared normal.suturingof the lacerationswas done withoutany fracture management. A month later, Apparently, progressive bonethe patient was transferred to V. Luna resorption resulted in an almost missingMedical Center and was subsequently right bony face. It was clear then that areferred to this institution. Physical large bone graft was needed to replaceexamination revealed the right eyeball to be these missing bones. The source of bonedisplaced downward and inward with severe graft became the problem since the popularloss of dght malar prominence. There was split thickness calvadal bone grafts willsevere nasal bone depression and facial surely not suffice. Considering theasymmetry. The conjunctivae of the right advantages of the calvarial bone grafts overeye was chemotic and there was ectropion the rib and lilac bone grafts, a full thicknessof lower lid as well as limitation of eye calvarial graft was harvested to reconstructmovement towards the medial side. The the facial bones.visual acuity was 20/80 (Jaeger) and patientcomplained of diplopia.SURGICAL MANAGEMENTThe patient was assessed to havethe followingcomminutedfracturesinvolving A coronal incision was outlinedthe right medial, inferior and lateral orbital behind the vertex and infiltration withwalls; nasal bone fracture; zygomaticbone lidocaineplus epinephrine (1:100,000) wasfracture:and rightmaxillarywallfracture, given before the incisionwas made. Theincision was brought inferiorly to the pre-The initialsurgicalmanagementwas auricularcrease at the level of the tragus.open reductionwith internalwire fixation of Hemostasisof edges was obtained by thethe fractures via Weber-Ferguson incision, use of Raney clips. The initial place ofIntraoperatively,comminutedfractures with dissectionwas just above the periosteumsome bone loss were noted at the medial over the central portion of the skull.orbital wall, zygomatic bone, orbital floor, Laterally, the incisionwas just above theinfraorbital rim, and lateral orbital rim. temporalismusclefascia. The dissectionisAdhesionsinthe fracturedsegmentsand on carried forward until the superior temporalthe right eye area were released. Despite fat pad was visualizedunderthe facia. Ansome bone loss, meticulousapproximation incision was then made through theof the available bony fragments with wire temporaUsfascia and the restof the incisionfixation was done. The patient was then was continuedsubfascially. This dissectiondischargedbut was later lostto follow-up, reflects the frontalis nerve anteriorly out ofharm's way. When the area of zygomatic

arch and lateral orbital rim was reached, the post-operatively. Patient was on generaldissection becomes subperiosteal in the liquids after 5 days, progressive dietnaso-frontal region. The dissection was thereafter. Patient was discharged on thecontinued subperiosteally down over the 10th post-op day. Staples were removed onroot of the nose and along the medial aspect the 14th post-operative day.of the orbit. With a marking pen, thesurgeon marked the area of the padetalbone to be harvested, taking care to stay atleast 2 cms lateral to the midline to avoidany possibility of injuring the saggital sinus.The dimensions of the graft was 8 x 10 cms.A full thickness calvadal bone wascompletely removed via a craniotomyprocedure. The harvested full thicknesscalvarial bone was horizontally divided intotwo with the use of a pneumatic air drill.Beforethereconstruction withOne half of the bone was split up with theMassive bone lossuse of a pneumaticair drill and malleable .......... ,_;_..-...

Craniomaxillofacial trauma and its use has been described in congenitalfacial reconstructive surgery is indeed a very craniofacial Surgery by Maralhac (1978),challenging field. As a result of altercation Tessier (1982), and Wolfe (1983), calvadalor vehicular accident, patient present with bone grafting has become popular for athe following givens: a severely fractured great variety of traumatic reconstructive andface in jigsaw pieces all jumbled. It is easy cosmetic facial deformities. In neurosurgeryto say that the pieces of the puzzle can be and spine surgery, the use of full thicknessput back together. But what must be done calvadal bone grafts for cervical spinewhen several pieces of the puzzle have fusions appears to be effective and safe inbeen lost? What could be done to restore pediatric patients requinng stabilization ofthe once admired face? the cervical spine. There was also lessmorbidity compared to autologous graftsThe advantages of 3D CT scan are from rib and iliac crest (Chadduck, 1994).indispensable here because it constructs a3-D model of the skull structure enabling Donovan reviewed 24 patientsproper evaluation of bone losses and reconstructed with split thickness calvadalpositions of the fractured bones,bone grafts and reported an overall successrate of 91.4%. Jackson (1992) reported 229Which exact surgical incision will split thickness calvarial bone grafts done onexpose fracture sites with least scarring is post-traumatic or congenital deformities inalso part of the challenge in maxillofacial the orbital area, attaining an 86%trauma. The coronal incision was used to satisfactory aesthetic and functional result.expose the skull as well as the areas of Minimal donor site morbidity was also seen.bone loss in the face thus facilitating harvest In a study of outer table calvarial bone graftsof the calvadum. Furthermore, the scars used for the reconstruction of the bonywould be all hidden when the hair grew orbital walls in 43 patients, the transplantsback. The gingivobuccal and infraciliary were harvested in the padetal area aboveincisions both provided good exposure and the non-dominant hemisphere. Theaccess sans postoperative scars,morbidity and complications rates at theharvest sites were extremely low. The graftsThe commonly employed iliac bone were all uneventfully incorporated (Spitzer,graft has been associated with 1994).complications. Some authors have opinedthat using the iliac crest as donor site hasSplit thickness calvarial grafts areproduced an unacceptably high degree of best harvested from the parietal regionpost-operative morbidity (Canady, 1993). measuring approximately 8 x 10 cm. In thisMathog cited postoperative pain as a area, the calvarium is thickest, and thedisadvantage. This complaint along with "danger areas" of concern in the midlinenumbness, infection, paralysis, or long term (saggital sinus) and temporal regionsdisability have been well documented. Most (thinner bone) are avoided (Frodel, 1994).patients were able to return to full activity Finkelman, et. al, (1994) showed that splitwithin4-6 weeks. Gluteal gait, aside from thickness calvarial bone grafts may havepain at the donor site were noted by Laurie greater survival as donor tissue than bone(1983). The main disadvantage of iliac bone from other sites. Split thickness calvarialgraft, being an endochondral bone, was its bone has been found to be resistant topropensity for resorption (Harbon, 1991). osteoporosis since calvadal bone containsFrodel and Mohr averred that membranous growth factors that may play an importantbones such as the calvarium undergo role in the regulation of bone repair.significantly less resorption. On the otherhand, rib grafts have produced With the help of a neurosurgeon, thepneumothorax and high rates of bone loss full thickness calvarial graft was safelyimmediately after bone grafting (lore, 1989). harvested with no complications such asdural tears, meningitis, CSF leak,An alternate source for bone intracerebral injury, subdural hematoma.grafting is the calvarium. Calvarial bone

This case made use of the fullCOMMENTSthicknesscalvadalbone graft insteadof themore common splitthicknesscalvadal bone 1. A fullthicknesscalvarialbonegraft can begraft becausethe latterwouldnot havebeen used safelywithoutany significantmorbidityadequate to replace massive bone loss. when the bulk of the splitthicknesscalvarialBesides, harvestingsplit thicknesscalvadal bone graft is not enough for bonegraft can resultto more fracturedgraftwhen replacementinmaxillofacialreconstruction.splittingisdone (Frodel, 1994),2. The applicationof the other advances inCalvarialgrafts have been shownto the management of maxillofacialtrauma isbe better accepted than the lilac and rib essential in the successful use of the fullgrafts providedthat the graftsare properly thicknesscalvarialbonegrafting.fixed and positioned. Inthis regard,the useof titanium plates for dgid fixation greatly 3. The procedure of harvesting the fullimprovedthe take as well as the designing thickness calvarial bone grafting is notand contouringof the bone graft for areas difficult but needs the service of awith bone loss. It reduced operating time neurosurgeon.and hastenedearly rehabilitation. Titaniummicro-platesare easily adapted to the bone 4. The psychologicaland emOtionalstatusofsurface and attains 3-dimensionalstability the patient in relation to the extent of thewith bone screws, With the titaniummicro operationis verysatisfactory,plating system, the harvest site of thecaIvadal graft was covered with the split 5. Financially,there is an additionalexpensethickness of one half of the calvarial graft, forthe neurosurgeon.This providedstrongand rigidfixationof thesplit thicknesscalvanal graft to protecttheskull, The other half was contouredto suit 1. BIBLIOGRAPHYthe area of bone loss. The platesare flat,avoiding contour defects or bulging, 1. Canady, at. al. Suitabilityof the lilac crest as a site forharvest of autogenous bone graft. Cleft-Palate-Contouring as well as designingthe bonecraniofacialjoumal. 30(6):579-81, 1993.graft are easily done becauseof the ability 2. Cummings, et.el.Frontal sinusfracture. OtolaryngologyHead & NeckSurgery.1986. p912.of the plating system to adapt to bone 3. Chadduck, Use of full thickness calvariel bone grafts forcontours, cervical spine fusions in pediatric patients. PediatricNeurosurgery.1994; 20 (1): 107-112.4. Donovan, Dickerson, at. el, Maxillary and mandibularThe surgeon'sexpertiseas well as reconstructionusing calvarial bone graft: a preliminary iaestheticjudgementare alsofactorsthat willreport. Journal ofOral-iaxillofaeial surgery. 1994Jun;52b (6): 588-94.help create the aesthetic and functional 6. Finkelman, Elevated IGF-iiandTGF-beta concentrationsrestorationof the facial features. The facialin humancalvarial bone:potential mechanismforincreased graft survival and resistance to osteoporosis.features of the patient have been Plastic ReconstructiveSurgery. 1994 Apr; 93 (4): 732-appreciablyrestoredsince bonecontoursfor 736.the lateral orbital wall, inferior orbital rim, 6. Frodel, j.I, et. al Calvarial Bone Graft Harvest:Techniques, considerations,and morbidity. Arch ofzygomatic area, alveolar ridge and nasal Otolaryngology Head & Nesk Surgery.1993; 119: 17-23.bridge have been created. A more 7. Gates. Strategies for approachingthe facial skeletal bytheway of extendedaccess approach. Currenttherapiessatisfactory and acceptable face has beenin Otolaryngology Head and Neck Surgery. 5th editionbestowedon the patient.The patienthadan 1994. p.147=149.uneventfulpostoperativeoutcomeandhad a _. Harbon,100 consecutiveet el. Morbidityofcases (Frenchlilac boneAnnallesgrafts.deAChirurgiestudyofhappierdispositionwiththe restorationof hisPlastique etEsthetique: 36(1): 45-50, 1991. (abstract)facial features. The calvarialgraft did not 9. Jackson.orbital reconstruction.ExperienceintheJournaluse of calvarialboneof Oral,cnexillofacialgrafts inhave any complications. In short, the surgery. 1992.April 30(2):92-6.patient'sonce lostface has been returned. 10. Mohr, et aL Osteoplastyof osseousdefects of the frontalbone and orbital roof:Application,techniqueend results(German Fortschriteder Kiefferundgesiehts 39 : 43, 1994(abstract)

Table XVBothersomeEffectsBothersome NGT OCT P Value (Mcnemars7, Drooling . (%) (,%), paired t-test)1,Nasat 82% 0

B.BothersomeEffects4, Nasa/Discharge (Rhinitis)1. Nasa/Pain Eightytwo percentof NGT subjectsexperiencednasal dischargewhile none forMajority, 65% (11/17), of NGT OGT subjects (see table VIII below).subjectshad a score of 2 while94% (16/17) Significant difference was noted betweenof OGT subjectshada scoreof 0. However, the two groups, p value

: : ::::: : : :::: :::_1 aSOphary;::i_it:rOd:uCed atong: the::fioo_:of: : :::: ::it r,eaChed:: the oiOpharynx ::::: .......: ........... _ose: ::and::::_hei_ :a_Vai_.ed 6w::iii_d : _,_o :the::::: each: ::::: :::::".:_t,_'_?_,

::: : positionl b:y: :aus:cultatiOn);the _:_t.tmbert ::::: Ccnf T0i:aio : atteT_pt:s:i_:ade: by the _sert6 piioii

OBJECTIVESThe objectives of the study is tocompare nasogastnc intubation and .,/,__-"_,.._orogastricintubationwithregardto: ,f \,..\/ .._(1) Ease of insertion / _,,_J _,TF _._" _%_.] \.(2) Occurrenceof bothersomeeffects / ............. "(3) Patients'acceptanceandpreference ! ......... tSIGNIFICANCE OF THE STUDY:Lookingfor betterwaysof delivering \. _ ,, ,/.#-basicimportantmedicalaspectservicesof medicalispractice.perhapsIfana%"\,,,,,,,_. ........ ,__¢,/_problemexistswith NGT, then a searchforalternativesis valid. OGT can be a viable Fig. 2. Distributionof Subjects by Sexalternativewhichwill effectthe same end asthat of the NGT butwith less problems.Thesignificanceof this studylies inthe eventualsearchfor such an alternativeespeciallyfor "indicationssuchas deliveringnutritionto thepatients._PATIENTS AND METHODS[_randomized, cross-over trial. Subjectsbetweenages This 15-37 wasyearsa wereprospective, includedin_ ?_wm_ . J[_),,q7_._.%_ )the figs. males study, 1-3). with There There a mean were were age two10subjectshowever,offemales 25 years and (see 7 %x_-_, ,,, .___......._i./_,/who were excluded becausethey were notable to tolerate the procedure. Fig.3. DistributionAccordingto Typeof Subject_Characteristics of the study populationareas follows:TableI_, Subject Age/Sex , Chm-_teristic'.J_ 1 31/F ' ' .l_mlormal "'2 15/F Normal,_:,_,i 3 20IF Normal;!" _' : 4 30/F Normal(t ,:_,x_= 5 2,5_ I,,C.hconioTympanosmastodlts' i i_ 6 20/I= NOrmal!._" J _l _ " 8 36/M ChronicTymparmsmast0idttisI 9 15/M ChronicTympenosmastoiditis_: / !!i !: i_ :!:! 10 25/M ChronicTyml_irmsmastoiditis•_l_.i _t 1: !_;.:;_i! i_t!i i.li i; _::i,"[;i _! :i i_'i i:_: '_........ • .:2 __: '::---.,,,,.,_,__121337/M24/FSkindefer, footNormal_ _ _ "_ _'.i. _;i, :.i ::;' _,; _,, 14 25/F Normal15 321F Normal16 28/F Normal_,':,_fi,Li'_ 'l"ii:_ 17 241F NormalInclusion criteria included:Fig. 1.Age Distribution 1.2.SubjectswhosignedinformedconsentSubjectswithoutmedical problems3. Subjectswithoutnasal or introralswellingand or lacerationsthat wouldinterferewithtube insertion

was then determined by asking preferred RESULTSreute of insertion.A. Ease of InsertionOGT VS NGT DATA FORMN_a:: __ Age/Se×: ' ' 1, Duration of InsertionAdclreas:Type of Subject:I. Ease of InsertionNo.IGrp.DAY I (OGT/NGT') Seventeen subjects who underwentOGT insertion and 13 subjects whoTImeelepsed (in minutes) underwent NGT insertions had both tubesNO.of attemptsa_scom_rtS,=reinserted in 1-3 minutes while 4 subjects whoRemarks: were included in NGT insertion neededI1.Bothersome Effects:l.pa_n between 4-6 minutes for the tube to beNasalc_esVNeck inserted via the naris. The mean durationOropharynxfor OGT insertion was 2.6 minutes while for2. Rhinitis [+]_ [-]_3.Naea_Obstruct_on [*t__ [4__ NGT insertion, 1.8 minutes (see table II4.Ga8 5. Speech Disturbance [*]_ [+]_ r-_ [-]_below). There was a significant difference67.DroolingOthers[+]-- ..... [']_ between the two groups p value

UNCOMMONCAUSE OF DYSPHAGIA*FRANKLIN C. ANG, M.D.**BERNARDO D. DIMACALI, M.D.***FIDEL P. BURGOS, M.D.***ABSTRACTDysphagiais a common ENT complaint but very seldom does an ENT specialistthink ofmyasthenia gravis as its cause, ptosis and diplopia being the usual symptoms. This is a case ofa 31 year old female with myasthenia gravis who presented with progressive dysphagia. A highindex of suspicion for early detection and proper management to prevent catastropic sequelae ofthe disease is emphasized.Keywords: Dysphagia, Myasthenia GravisINTRODUCTIONMyasthenia gravis has been condition presented about 8 months beforeextensively studied for the past 3 centuries admission, while patient was 3 monthsbut, up to now, still has an obscure etiology, pregnant, as difficulty in swallowing solidAntibodies to acetylcholine receptor protein foods, incomplete closure of both eyes andfrom the thymus gland as well as a virus- nasal twang (worsening as the day wore on),induced injury on the thymic cells have sensation of a mass blocking thebeen considered but what stimulates the esophagus, difficulty in spitting (such thatproduction of these antibodies and where saliva had to be scooped out with tissuethey are formed are still unclear. The paper), headache and yellowish nasalunpredictability of its onset, the discharge. A private physician diagnosedconsiderable distress that accompanies it the patient to have sinusitis and prescribedand the possibility of bulbar and multiorgan minocycline (MINOCIN) andfailure make further etiologic studies phenylpropanolamine Hcl (DIMETAPPimperative.EXTENTABS) which afforded relief of allsigns and symptoms. Patient wasNot all patients with myasthenia asymptomatic during the rest of thegravis have the same type of dysfunction, pregnancy which terminated without anyMost of them have ptosis and diplopia while untoward event. Three months beforeothers have orbicularis oculi muscle admission, the same signs and symptomsinvolvement and dysphagia,recurred with progression of dysphagia toliquids. Another private physician gave theThe primary focus of this paper is same diagnosis and prescribed cotheimportance of early diagnosis of amoxiclav (AUGMENTIN 375 mg),myasthenia gravis presenting with an ergotamine tartrate, mecloxamine,uncommon symptom in order to prevent or phenylpropanolamine and cinnarizine but toat least to delay the progress of the disease no avail. She was then referred to an EENTto myasthenic crises,specialist who gave the same diagnosis andprescribed astemizole (HISMANAL), co-CASE REPORT trimoxazole, neobromexan and ambroxol_The medications were taken for only 2 daysG.R., 31 years old, female, from because "it aggravated the signs andQuezon City was admitted for the first time symptoms". The patient was referred by anin this hospital on January 22, 1995 internist to this hospital and wasbecause of difficulty in swallowing. Thesubsequently admitted." Presented,PSO*HNS,ClinicalCaseReportContestApril7, 1997,Subi¢internationalHotel,OlongapoCity** Resident,Departmentof ENT, F.E.U.-N.R,M.F.*** Consultant,Departmentof ENT, F.E.U.-N.R.M,F,

Stimulation of the right spinal accessoryPast medical history included a nerve showed 11% decremental responsediagnosis of PTB by chest X-ray in 1993 for during pre-exercise, 40% decrementwhich she was given SCC kit for 8 months immediately post-exercise and a 26%with no follow-up thereafter. In January decrement 2 minutes after exercise. The1994 patient had a history of forcefulvomiting, was diagnosed to have an ulcerresults are consistent with post-synapticneuromuscular transmission defects such asand was given ranitidine, myasthenia gravis. Patient's dischargediagnosis was myasthenia gravis, Class IIA.On physical examination there waspooling of saliva at the oropharyngeal areaand incomplete closure of both eyelids. DISCUSSIONAssessment then was esophagealobstruction etiology unknown RIO Three centuriesago Thomas Williscarcinoma, mild left nasal septal deviation described the signs and symptoms ofand impacted cerumen,AU. myasthenia gravis (MG). But, it was Erbwho called-thedisease as suchand definedOn admission,a Fr. 16 nasogastric it as a bulbar palsy without an anatomictube (NG'r) was inserted without anydifficultyand osterizedfeeding was startedlesion. In 1932 the use of physostigmineasa form of treatmentwasdemonstrated.at 2,500 cal/day (Carbohydrates = 65%,Protein= 25%. FATS = 10%). Bloodcount,MG is a muscularweaknesswith aelectrocardiogram,fasting blood sugar and grave prognosis. Repeated or persistentserumcreatininewere normal. The chest X- activity of a muscle group exhausts itsray revealed pleuraltuberculosisat the left contractile power, leading to progressivelung apex. paresis. Rest restores strength, at leastpartially. The demonstrationof these twoUpon removal of the NGT prior to attributes is enough to establish thean esophagogram, patient noticed some diagnosis, assumingthe patientcooperatesimprovement in swallowing,swallowedthe fully. The onset is usually insidious, butbarium with ease and refused to have the there are instances of fairly rapidNGT reinserted. Esophagogram revealed development, sometimes initiated by ansatisfactory opacification of the entire emotional upset, infection, some drugs usedesophagus without any filling defect, during anesthesia, pregnancy or thedeformity or obstruction. Esophagoscopy puerperiurn. In this case, the symptoms firstdone on the second hospital day showed appeared during pregnancy and 3 monthsspastic cricopharyngeus muscle beyond post-parturn. The fluctuating nature ofwhich no abnormality was noted. Patient myasthenic weakness is unlike any otherwas then referred to neurology service disease. The weakness varies in the coursewhich considered myoneural junction of a single day, sometimes within minutes,disease (Myasthenia gravis vs. Guillain and it varies from day to day, or over longerBarre Syndrome). Mestinone 30mg QID was periods. Myasthenic symptoms are alwaysstarted and repetitivestudies suggested.nerve stimulation due to weakness, not to rapid tiring.Another characteristic of MG is theAfter giving 2 doses of mestinone, distribution of weakness. The levatorpatient was relieved of all the signs and palpebrae and extraocular muscles aresymptoms, recurring only upon physical affected first in about 40% of cases and areexertion. Two days later, patient hardly ultimately involved in about 85 to 90%.complained of any signs and symptoms and Ptosis and diplopia are the symptoms thatwas discharged on the 7th hospital day. result. But, in this patient, it was theorbicularis oculi muscle that was firstRepetitive nerve stimulation studies involved, manifested as incomplete closureon the right ulnar nerve with a stimulation of both eyes. There was no diplopia.rate of 5 Hz showed a 10% decrement at Weakness tends to increase as the daypre-exercise period, a 7.4% decrement wears on but patients seldom volunteer thisimmediately post-exercise and 14.2% information. The course of the illness isdecrement 2 minutes post-exercise, extremely variable. Rapid spread from one

muscle group to another occurs in some,but in others the disease remainsmolecule, which controls an ion channel,has multiple binding sites for Ach.unchanged for months before progressing. Attachment of the latter to the receptorWeakened muscles in myasthenia gravis molecule opens an ionic channel in theundergo atrophy in only a limited number of receptor membrane for the influx of sodiumcases (about 10% in females and 20% in and the efflux of potassium. Themales); the atrophy is rarely marked in neurotoxin, alpha-bungarotoxin, a smalldegree. Tendon reflexes are seldom polypeptide, has a high affinity for theaffected. Normal pupillary responses to binding site and, like the receptorlight and accommodation in the face ofweakness of extraocular muscles andantibodies, blocks the attachment of Ach ordestroys in some manner the receptororbicularis oculi are virtually diagnostic of membrane. C3 complement is also involvedmyasthenia gravis, especially if strength is in the immunologic blockage.restored after a period of rest. The tonguemay display one central and two lateralDiagnosis in patients who presentlongitudinal furrows (trident tongue),with typical myasthenic facies like unequaldrooping eyelids, relatively immobile mouthThe prevalence of MG is variously turned down at the corners, a smile thatestimated at 43 to 84 per million of the looks like a snarl, and a hanging jawpopulation. The peak age of onset in supported by the hand can hardly bewomen is between 20 to 30 years, while the overlooked. Other tests are:male incidence peaks in the sixth or seventh1. Decrementing response - rapiddecade. Remissions may take place reduction in the amplitude of compoundwithout explanation, but if the disease muscle action potentials evoked duringremits for a year or longer and then, recurs, repetitive stimulation of a peripheral nerveit tends to be progressive,at a rate of 3/sec.2. Edrophonium (-iensilon) Test -To facilitate clinical staging of - Adult - IV - 0.2ml (2mg) is injected withintherapy and prognosis the following 15 to 30 second, the needle is left in situ. Ifclassification was introduced by Osserman: no reaction occurs after 45 seconds, theI. Ocular Myasthenia remaining 0.Sml (8mg) is injected IM If (+)II. A. Mild generalized myasthenia with slow for reaction (cholinergic reaction like muscleprogression; no crises; drug responsive,weakness), patient should be retested afterB. Moderate generalized myasthenia; 0.5hrs with 0.2ml (2mg) of tensilon IM tosevere skeletal and bulbar involvement, but rule out false negative reactions. (The doseno crises; drug response less than in children is 1 mg for weight up to 75 Ibs.satisfactory, and 2 mg for those over 75 Ibs.). If aIll. Acute fulminating myasthenia; rapid cholinergic reaction (muscarinic sideprogression of severe symptoms with effects, skeletal muscle fasciculations,respiratory crises and poor drug response; increased muscle weakness) occurs afterhigh incidenceofthymoma; highmortality, injection, the test is discontinued andIV. Late severe myasthenia, same as III but atropine sulfate 0.4 to 0.5 mg is given IV.progression over 2 years from Class I to I1.3. Neostigmine Test NeostigmineAntibodies to Acetylcholine (Ach) methysulfate is given IM at 1.Smg. Positivereceptor protein have been found in test also shows improvement of muscleapproximately 85% of patients with weakness, but a negative test does notgeneralized myasthenia and in 60% of those exclude MG.with ocular myasthenia. The nicotinic Ach 4. Measurement of Acetylcholine receptorreceptors are located in the crests of the antibodiesfolds of the sarcolemma beneath the nerve Previous belief held that there was afiber terminals, in a density of approximately decrease in the amount of acetylcholine but,30,000 per square micrometer, and are also nowadays most authors believe that there ispresent in mammalian thymus gland. The destruction of the Ach receptor.receptor substance is a highly specializedglycoprotein, spanning the lipid layer of theTreatment of this disease involvespostsynaptic membrane, with a molecular the careful use of three groups of drug -weight of 300,000 daltons. Each receptor anticholinesterases, immunosuppressants,

and corticosteroids- and of thymectomyand plasmaphoresis. The oral dose ofBIBLIOGRAPHYneostigminerangesfrom 7.5 to 45 mg every 1. Adams and Victor: "Myasthenia gravis2 to 6 hourswithaverage maintenancedose and episodic forms of muscularof approximately150mg per day. But, a weakness".Principlesof Neurology,_hstudydone by Breyer et al in 1988 indicated edition,1989. Chap. 53; 1150-1165.that pyridostigmine(neotigmine) at levels 2. Breyer-Pfaff et al: =Neuromuscularabove 100mg/ml may impairneuromuscular function and plasma drug levels infunctionand may producecholinergiccrisispyridostigminetreatment of myasthenia(muscarinic effects like nausea, vomiting,pallor, sweating, salivation, colic, diarrhea,gravis".Journalof Neurology1989; 502-5-5.miosis and bradycardia). Thymectomy is 3. Durelli et al: "Total body irradiationforrecommendedin practicallyall patientswithmyasthenia gravis: a long term followuncomplicatedMGwho are less than 45 toup". Presented in part at the 42rid50 years of age and who, after a period of annual meeting of the Americantreatmentwith antlcholinesterasedrugs, arerespondingpoorly and requiringincreasingAcademyof Neurology,Miami, FL, May1990.dosesof medication. 4. Gajdos et al: "A randomizedclinicaltrialcomparingprednisoneand azathiopdnePrednisone40 to 45 mg/day may be in myasthenia gravis. Result of thegiven twice this dose every other day for the second interim analysis. Journal ofmoderately severe myasthenic, in whom a Neurology, Neurosurgery andremission has not been induced by Psychiatry 1993;56:1157-1163.thymectomy and who is responding 5. Gautel et al: "Titin antibodies ininadequately to anticholinestrase drugs, myasthenia gravis: Identification ofStriking temporary remissions of 4 to 6 major immunogenic region of titin"_weeks may be obtained by the use of European Molecular Biology Laboratory,plasmapheresis (5 daily plasma exchangesVienna, Austria: and the Department ofevery 5 weeks) in cases of myasthenic Neurology, University of Bergen,crisis. Azathioprine in a dose of 2.5 ml/kg Haukeland Hospital, Bergen, Norway.daily with prednisone in doses up to 1.5 1993.mg/kg per day may increase treatment 6. Nakano et al: "Myasthenia gravis:response compared with prednisone alone. Quantitative immunocytochemicalOther cytotoxic drugs such as methotrexate, analysis of inflammatory cells andcyclosporin, with or without antilymphocytic detection of complement membraneserum, or total lymphoid radiation, are also attack complex at the end-plate in 30being tried in patients who continue to do patients. Journal on Neurologypoorly after thymectomy. Eventually, there 1993;43:1167-1172.may be remission, hence the justification for 7. Penn and Rowland: " Neuromuscularusing every possible measure to support the junction". Merritt's Textbook ofpatient until this happens. Neurology, 8th edition, by Lewis P.Rowland, 1989. Chap. XVl; 697-705.8. Sano et al: "Enzyme immunoassay ofCONCLUSION anti-human acetylcholine receptorautoantibodies in patients withThis case report highlights an myasthenia gravis reveals correlationunusual presentation of MG and with striational autoantibodies. Fromemphasizes the inclusion of MG in the the Department of Neurology,differential diagnosis of patients with Immunology and Laboratory Medicinedysphagia. This strategy leads to early and Pathology,Mayo Clinic, Rochester,diagnosis of the disease and better MN. 1992.treatmentoutcomes.

Y-FLAP AND RIB CARTILAGE GRAFT IN THEINITIAL STAGE OF PARTIAL AURICULARRECONSTRUCTION AFTER TUMOR SURGERY*FELIXBERTO D. AYAHAO, M.D.**ABSTRACTThis paper reports the use of Y-Flap from the pre- and post-auricularareas for tissuecoverage of autologousrib cartilagegrafts in the reconstructionof the ear of a 72 year old malewhohadsquamouscell carcinomaof the left pinna.The post-operativecomplicationnotedwas atip necrosis of the anterior flap which was easily remedied by debridement and furtheradvancement of the flap.Keywords:Partial auricularreconstruction,squamouscell carcinoma,pinna, y-flap, autologusribcartilage graftINTRODUCTIONCases encountered by the patient still desired an ear but would likeotolaryngologists needing auricular as few trips as possible from the provincereconstruction due to trauma, tumor surgery where he lived. Because silastic implantsor congenital defects demand a variety of are not readily available and have a highsurgical approaches dependingent on the failure rate while bilobed flaps would benature, size, and location of defect, inadequate to cover the anterior andeconomic factors and social demands. This posterior surfaces of a reconstructed pinna,paper submits for judgment one of the ways an autologous rib graft was considered.to approach this problem.Although proven to be durable inauricular reconstruction, rib grafts can failCASE REPORTdue to resorption or warping. This problem,however, can be minimized by minimalA 72 year old male with a dark sculpting and preservation of somediscolored ulcerating lesion of the left pinna perichondrium for immediateof 5 years duration was diagnosed to have revascularization. The preferred rib donorsquamous cell carcinoma by biopsy. Patient sites are the 6th and 7th rib contraleteral topreferred radiotherapy to surgery but was the auricle being reconstructed to takelater lost to follow-up. One year before advantage of the rib configuration.admission, the lesion recurred and wasagain biopsied revealing basal cell To provide for skin cover, a Y-flapcarcinoma. Progressive spread of the mass was designed with the superficial temporaldespite herbolario treatment prompted and posterior auricular arteries as feedingconsultation and subsequent admission, vessels. The rich blood supply of theMOHS excision was planned with the option periaL_ricularegion arises from the externalto reconstruct the defect with a bilobed flap, carotid artery by way of the superficialrib graft or silastic implant. Ideally, temporal artery anteriorly and from thereconstruction after tumor surgery should be posterior auricular artery behind. Thedelayed for at least one year to observe for venous drainage enters the superficialtumor recurrence. However, immediate temporal vein in front and external jugularpartial reconstruction was planned because vein below. In most cases, there is an"2"dPlace, PSOHNS SurgicalCaseReportContestApril 8, 1995,Subic InternationalHotel, OlongapoCity**Resident,Departmentof Otorhinolaryngology, Universityofthe Philippines-Philippine GeneralHospital

......... _....... ::: :::::: :::::::::::::: : aid: :posb_auricular rotation : :: ::: ..... *_'_''_:: :.: _':: : : _=fap was made cove-ng the : :: :: [::::::[:...... ::::: ........... .............. :: : a fte:rio'_ surfaces :of 1he.... : ::: :: :pinna :defect ::i[

: nec_'oSi:S:: oi!::: iiie tip :of _he::aniedoi: flap and :: :......... ::::this:was :attfiiouted to ::poor-blood supply :: : :::: wlien:the:fl:ap:took::a: dip ptureii : ::::::cuiwe:: iii ::tii:e:::::::ai_tPhelix :t:o:: pressure ::: ::::dressh_:9:i::_::h:iS::::howeve_ was: yclosed : : ::,. later b:y::} :::debtdemen:t fu "ther::::tgi : :adVaficei_:eit Of! the :fap ng was : ..... ................ : : :: :: ent and: ii re at ves.......... ........ vei .............. :::: ::ii!:':!{!:: ::: : taking:Care of tumor`recerr`enCeiate_-: if:[le _e:: :: ::airy: If:reconstrLct:dn: s::deayed the :::: iri: [he ::surro_l_d a"eaS ::::: : :: :: reconst:rUc[N,e:because of ::i: {::tissi.i:ei:::elasticity: and compromised : ::: : ::::: ::: :will be the fibroS:S:a " : ::::::::::::: :: split : :::thickness sk 9raft careful y:: :i:: :the:Supe_i_iaJ:iteiit_poraJ arteiT ::: ::: : ::::::::}::: :: : : : : :an ::iempol:alisfasii.:i [4_aftlining: :: :....::::::::::::::::::::::::::::: tempOralis:ra(!ia::is '_:tL°r_" :: ::: :: : coveiied:::wi:[h::: graft..................... tmmediat6 :::e,x(JSion oh is: :...... ::::::: :::: ::::::::::: ::: ::::::: ............. is :aiWaysi:preferable" to : : :::

detected early another excision and This paper described the role of areconstructionof a smallerdefect iseasier. Y-flap basedon pre- and post-auricularskinin providingskin cover for cartilage ribIn retrospect, tumor excision and grafts used in reconstructingthe pinna. Thedelayed reconstructionto observefor tumor advantage of using the flap is its goodrecurrenceis ideal. One year of observation vascular supply and excellent skin coloris adequate enough. To approximate the matchforthe auricle.normal auricle, multiple stages ofreconstructionare required especiallyif thefour basic componentsof the pinna--- theBIBLIOGRAPHYhelix, scapha, antihelixand concha---are tobe reconstructed. In instances where 1. Brent and Brent; The Artisty ofimmediate reconstruction is possible, theReconstructiveSurgery Copyright1987proceduredescribed in this paper could beby C.V. MosbyCompanyused. 2. Friedman and Constantino; TheOtolaryngologic Clinics of NorthAmerica. Feb. 1994SUMMARY 3. Strauch et al; Grabb'sENCYCLOPEDIA OF FLAPS vol. 1There are many ways of 1sted. 1990reconstructingthe auricle, whether total or 4. Donald; Head and Neck Cancer,partial.Proceduresare not uniform as theyManagementof the DifficultCaseam on a case to case basis especiallywithregards to size, location and character ofdefect.