CALENDAR OF EVENTS 2006 - MSO-HNS(c)Non-pneumatization of the mastoid In very young children, pneuma-tization of the mastoid bone is still incomplete. Most areas of the mas toid are

Volume 1, Issue 1

MSO-HNS Newsletter Page 11

Dato’ Dr Gurdeep Singh Mann,

more fond ly known as the

‘Merdeka Boy’ by those close to

him, was born on Independence

Day, 1957. He obtained his

post-g r a d u a t e q u a l i f i c a t i o n

i n ORL-HNS from Universiti

Kebangsaan Malaysia. He has

served as Head of Department

of ENT, Hospital Ipoh, for the

past 16 years. In addition to his

admin is t ra t i ve work , he i s

act ively involved in c l in ical

THE PRESIDENT ELECT

practice, teaching and research.

He has held various positions in

professional bodies such as the

MSO-HNS, Malaysian Medical

Association and the Malaysian

Society of Allergy and Immuno-

logy. He i s a lso an ac t i ve

sportsman with a particular

love for hockey and golf. He is

married to Datin Mungit Kaur

and has three grown-up sons,

of which two are currently in

medical college.

Paediatric Otolaryngology:Where Paediatricians Talk To ENT SurgeonsHilton Hotel Petaling Jaya8th of April 2006, 2.30 pm to 7.00 pm

5th Rhinoseptoplasty & Aesthetic Surgery WorkshopHospital University Kebangsaan Malaysia (HUKM)9-10 April 2006

26th Malaysian Society of Otorhinolaryngologists -Head and Neck Surgeons (MSO-HNS)Berjaya Langkawi Beach Resort & Spa Resort,Langkawi Island, Kedah, MalaysiaAGM 26-28 May 2006

1st Neuro-Otology Course & 26th TemporalBone Dissection WorkshopHospital UKM, Cheras, Kuala Lumpur4th-8th September 2006

2nd UPM-UMMC FESS CourseDetails to be announced

CALENDAR OF EVENTS 2006

Volume 1, Issue 1

Workshops on various audio-

logical tests were well received

by the audience. Of course the

interesting areas of discussion

were the latest technology in

auditory rehabilitation including

cochlear implants and bone

anchored hearing aids (BAHA).

The second day deal t wi th

topics related to vertigo and

neuro-otology.

Together with this workshop

a s y m p o s i u m o n v e r t i g o

management was he ld fo r

genera l p rac t i one rs aga in

attracting a group of about 40

genera l p rac t i t i oners f rom

around the Klang Valley. Basic

t o p i c s i n v e r t i g o a n d i t s

assoc ia ted p rob lems were

discussed. A hands-on demo

was conducted by Dr. Niramon

showing the various techniques

employed in deal ing with a

patient with BPPV.

The course was conducted in

Westin Hotel in Bukit Bintang

on the 25th and 26th of February

2006 with invited faculty from

the Philippines, Dr. Norberto

M a n t i n e z a n d A s s o c i a t e

Professor Dr. Niramon from

Thai land. Speakers loca l ly

i n c l u d e d D r. K u l j i t S i n g h ,

Professor Dr. Din Suhaimi, As-

sociate Professor Dr. Prepageran,

Professor Dr. Lokman Saim, Dr.

Long Chin-Wan and Dr. Asma

Abdullah. The participation was

very encouraging with almost

80 people majority of which were

postgraduate students in Oto-

rhinolaryngology as well as

both private and government

ENT surgeons. Topics covered

included subjects related to the

auditory and vestibular system.

MSO-HNS Newsletter Page 13

AUDIOLOGY AND VESTIBULAR WORKSHOP

2006 AND OTOLOGY REVIEW

The participation

was very

encouraging

with almost 80

people, the majority

of which were

postgraduate

students in

Otohinolaryngology

as well as both

private and

government

ENT surgeons.

Dr. Jeevanan Jahendran

Exco MSO-HNS

Dr. Niramon demonstrating techniques on managing BPPV patientsduring the hands-on demonstration

Volume 1, Issue 1

RESEARCH ACTIVITIES IN LOCAL

INSTITUTIONS FOR 2005-2006

A Serial Evaluation of the Effects

of Gamat on the Healing Process

of Tympanic Membrane Perforations

in Guinea Pigs.

A Study of Hearing Disorder and

Ear Disease in Kelantan and

Terengganu.

The Effect of Minimal Hearing

Loss on Academic Schoo l

Performance of Primary School

Children in Kuala Terengganu.

Health Related Quality of Life

Assessment in Treated Head

and Neck Cancer Pa t ien ts

Cephalometric Assessment in

Snorers and Non Snorers in

Children.

Brush Cytology in Comparison

with Histopathological Examina-

tion in Nasal Tumours.

UPM

Multiplex PCR of EBV DNA in the

detection of recurrent and residual

nasopharyngeal cancer (MAKNA

Cancer Research Award Grant).

Presence of house dust mites in

the ear wax of patients with otitis

externa.

Desloratadine in patients with

persistent Allergic Rhinitis.

Quality of Life Reduction with

persistent Allergic Rhinitis.

Mental and Emotional Changes

with Persistent Allergic Rhinitis.

Ophtalmological Symptoms in

Patients with Persistent Allergic

Rhinitis.

Epidemiology of Allergic Rhinitis in

Malaysia.

Hospital Ipoh

Review of Salivary Gland Surger-

ies 2002 – 2004.

Endoscopic Assisted Transseptal

Transphenoidal Hypophysectomy

Review of Deep Neck Abscesses

2002 – 2004.

Review of Myringoplaties 2004.

Outcome and Hearing Gain.

Voca l Rehab i l i t a t ion Pos t -

Laryngectomy.

Anatomic Variation of Paranasal

Sinuses based on CT scans.

Magnesium therapy for sudden

sensorineural hearing loss.

Success of speech therapy for

vocal cord nodules.

Cisplatin induced ototoxicity in

NPC patients.

BSER among high-risk groups.

Private Institutions

Mr. SP Palaniappan (Glean-

eagles Medical Centre, Penang)

Benef ic ia l e f fec ts o f Z Net

(permethrin impregnated sheets

for the mattress and pillows) to

control house dust mite induced

allergic rhinitis and asthma.

UKM

Efficacy of Amphotericin B nasal

irrigation in chronic rhinosinusitis.

Double blind placebo controlled

study of the effects of probiotics

(lactobacillus parasei 33) on

allergic rhinitis patients in HUKM.

Paediatr ic coblat ion versus

conventional tonsillectomy. A

randomized single blind study

Ultrasound guided Botulinum toxin

A injection in a drooling patient.

Radiofrequency tissue volume

reduction of soft palate in snoring

Distortion product otoacoustic

emission and contralateral sup-

pression of distortion product

otoacoustic emission in tinnitus

A cross sect ional s tudy of

nasal anatomic var iat ion in

chronics inusitis patients requiring

functional ESS. The efficacy of

topical mitomycin to prevent

adhesion formation post ESS.

Retrospective review on the

incidence of middle ear effusion

in c lef t palate chi ldren and

management outcome in HUKM.

Identification of digenic mutation

of GJB 2 and GJB 6 among school

children.

USM

Study on Prevalence of OSAS in

Children with Adenotonsil lar

Pathology in HUSM – A Pilot Study

In Vitro Study of Tea Tree Oil Effect

on Tissue Growth and Common

Microorganism in Chronic Sup-

purative Otitis Media.

The Comparative Value of Frozen

Section Microscopy and Fine

Needle Aspiration Cytology in

Thyroid Nodules in Predicting

Malignancies.

Evaluation of Nasal Cavity Geo-

metry Using Acoustic Rhinometry:

A Cross-sectional Study Among

Normal Subjects at Hospital USM.

The Accuracy of Sterolithographic

Model of Sinonasal Anatomy

Compared to CT scan and Subject

Measurement.

In Vivo Study of Sea Coral Graft

in Rabbits.

MSO-HNS Newsletter Page 15

Research Activities

in Local

Institutions for

2005-2006

Volume 1, Issue 1

SURGICAL ISSUES IN COCHLEAR

IMPLANTATION IN VERY YOUNG

CHILDREN AND CHILDREN WITH

INNER EAR ABNORMALITIES

Lokman Saim

MD (UKM), FRCS (Edin.),

MS (ORL-HNS) UKM Professor,

Department of Otorhinolaryn-

gology, Universiti Kebangsaan

Malaysia

In the beginning only profoundly

dea f adu l t s w i t h acqu i red

deafness a f te r deve lop ing

speech and language skil ls

were considered for cochlear

implantation. Nowadays cochlear

implants have proven to be

effective and reliable not only in

the postlingually deaf adults, but

also in congenitally deaf and

prelingually deaf children. Due

to the increasing experience

and improvement of implant

technology, the selection criteria

has been further broadened.

Amongst the main extensions are

implantation in the very young

children below the age of two

implantation in patients with

inner ear abnormalities. Both

condi t ions were prev ious ly

considered as contrain-dications

for cochlear implantation. In both

condi t ion the surgeon may

encounter difficulties in electrode

insertion and other intra and

postoperative surgical problems.

Generally in prelingual deafness,

the conditions for successful

cochlear implantation become

more unfavorable with increasing

age of the child. In majority of

cases, these prelingual deaf

children are implanted at age

between 2 to 4 years. Clinical

experience indicates that a

child suffering from congenital

hearing loss will most likely have

normal or near normal speech and

Page 16

“In the beginning

only profoundly deaf

adults with acquired

deafness after

developing speech

and language skills

were considered

for cochlear

implantation”

MSO-HNS Newsletter

to defer surgery in cases of

acute otitis media and otitis

media with effusion. Perfor-

ming a cochleostomy in the

presence of effusion risks

introducing bacteria into the

cochlear caus ing labyrinthi

tis and meningitis.

( c ) Non-pneumatization of

the mastoid

In very young children, pneuma-

tization of the mastoid bone is

still incomplete. Most areas of

the mas toid are bone marrow

spaces. The surgeon may

encounter troublesome bleed-

ing during cortical mastoidec

tomy. However this can be

adequately controlled using

the diamond burrs or appli-

cation of bone wax.

(d ) Relatively small size of

the mastoid and middle ear

The size of the middle ear and

mastoid is relatively smaller

in very young children. There-

fore the space for posterior

tympanotomy is limited. A full

range of smaller size burrs

will be helpful.

(e ) Facial nerve injury

In very young children, the

vertical segment of facial

nerve transverses the mas

toid bone more superficially.

Therefore it is more prone to

injury during mastoidectomy

and posterior tympanotomy.

In inexperienced hands, use

of the facial nerve monitor

is advised.

language acquisition if implanted

before the age of four. As such

itwould be ideal if implantation can

be performed as soon as the

diagnosis is confirmed and other

audiological conditions fulfilled.

With increasing experience and

availability of better audiological

tests, th is can certa in ly be

achieved before the age of two

years. This is happening in

hospitals that implement the

policy of universal newborn

hearing screening. Besides the

problem related to anesthesia

and o ther genera l medica l

challenges in surgery in very

young children, special problems

related to cochlear implant

surgery includes:

(a ) Thin skull bone at the site

for receiver stimulator bed

In children below 2 years the

thickness of skull at the site

may be only 2 mm or less.

Thus the whole thick ness

of bone has to be removed

exposing the dura for a very

thin island of bone at the center.

This allows the dura to be

pushed slightly downwards to

accommodate the receiver

stimulator. Care ought to be

taken during the drilling to

prevent tear of the dura and

CSF leak.

(b ) Otitis media

The probability of otitis media

during implantation is higher

in very young children. There-

fore preoperative evaluation

to exclude otitis media is im

portant. The author prefers

Volume 1, Issue 1

( f ) Thin scalp

The receiver stimulator when

placed beneath the scalp in

very young children may be

felt as a bulge and therefore

may be at a higher risk of in

jury or damage. The inci dence

of extrusion is not expected

to be much higher compared

to older children or adults.

IMPLANTATIONIN

PATIENTS WITH INNER

EAR ABNOR-MALITIES

At surgery the surgeon is to place

the electrode array into the scala

tympani of the basal turn and

insert the electrode coil as much

as possible towards the apical

turn. This is usually achieved with

ease in the majority of cases when

the structure of the cochlear is

normal. There are nevertheless,

some ears with abnormalities

of the cochlear that can make

insertion of the electrode array

more challenging.

Acquired abnormality –

Osteogenesis of the

cochlear

T h e c o m m o n e s t c a u s e o f

os teogenes is labyr in th i t i s

ossificans following meningitis.

The usual route of entry of the

organism is along the cochlear

aqueduct. Therefore the most

common s i te o f new bone

formation is the scala tympani

close to the round window. It will

progress further down the scala

tympani with time.

SURGICAL SOLUTIONS

Scala tympani insertion: In osteo-

genesis it is sometimes still

possible to clear new bone from

the round window area if the new

bone has not extended around the

hook of the basal turn using the

microdrill. In these cases it may

be possible to insert at least 15

electrodes through the scala

tympani.

Scala vestibuli insertion

To enter the scale vestibuli, it

is necessary to obtain a clear

view of the stapes by extend-

ing the posterior tympanotomy

superiorly. The crura of the

stapes is then divided. The

surgeon can use a microdrill

to perform the cochleostomy

to insert the electrodes.

Use of Nucleus Double

Electrode Array

Several surgical techniques have

been prescribed for cochlear

implantation in the completely

ossified cochlea. Most of them

are based on the pr inc ip le

of intracochlear positioning of

several electrodes. This involves

drilling out the new bone from

the basal turn of scala tympani

and insertion of a limited number

of electrodes. Cochlear Ltd deve-

loped a new spl i t electrode

array to enable the placement of

all active electrodes into the

cochlea. The first array which is

placed at the lower basal turn

has 11 active electrodes while

the second array is placed in

the second turn of the cochlea

with 10 active electrodes. The

double array provides additional

treatment modalit ies for the

ossified cochlea.

Congenital abnormalities

of the cochlea

The arrest of maturation during

one of the s tages of inner

ear embryogenesis leads to

various morphologic patterns.

The spect rum of inner ear

mal fo rmat ions may ex tend

from mild abnormalities of the

semicircular canals to complete

labyrinthine aplasia (Michel

deformity). The most oftenen-

countered inner ear anomaly

suitable for cochlear implanta-

tions is the Mondini deformity.

This malformation was described

by Car lo Mond in i and was

characterized by a cochlea

shor tened to one and ha l f

turns and lacking a complete

intercalary septum. In reality

There can be complete lack

development of the otocysts so

that only a single cavity is present

called the common cavity. All

these abnormal i t ies can be

predicted by high resolution CT

scans preoperatively. The author

has also encountered 2 cases of

anatomic abnormality of the basal

turn which makes it difficult to

identify the round window and

promontory. Insertion in Mondini

deformity and Common Cavity

Abnormalities. In Mondini abnor-

mality, if over one and a half turns

of the cochlea exist, there is little

difficulty inserting the cochlear

implant electrodes in the usual

manner. In common cavity abnormal-

ities, the cochleostomy is created

at the most prominent area of

the bulge of the common cavity.

Co chlear implantation in Mondini

deformity of common cavity may

result in perilymph gusher which

is actually CSF flowing into the

cochlear cavity via a patent

cochlear aqueduct or via the

internal auditory canal. This can

be managed with a tight fitting

electrode array at the electrode

entry point and packing the area

with muscle or fibrous tissue.

MSO-HNS ACTIVITIES 2005-2006

JanuaryAnnual ENT Health Camp held on the 15th of January2005 in Kuala Selangor.

April3rd KL Rhinoplasty and Aesthetic Course & Live SurgeryDemonstration, 29-30 April 2005, UKM, Kuala Lumpur.

MayMSO-HNS AGM: in Putrajaya.

AugustUPM-UMMC 1st FESS Course, 13-14 August 2005,UPM/UMMC.

SeptemberOtology, Neurotology & Skull Base Update and BoneAnchored Hearing Aid Workshop, 8-9 September 2005in UMMC.

NovemberThyroid Surgery Updates for ENT Surgeons, 20th

November 2005, KL Hilton.

DecemberAsean Research Symposium on Rhinology, 30November- 3 December 2005, KL Hilton.

January 2006Langkawi International Temporal Bone CourseAwana Porto Malai, Langkawi18-20 January 2006

March 20062nd NUH-HUN Otolaryngology Head & NeckConferenceNational University Hospital, Singapore21-24 March 2006

ORL-HNS Scientific Meeting 2006Renaissance Hotel, Kota Bahru25 March 2006

Kem Cakna Kesihatan Telinga Hidung Dan TekakPulau Redang, Terengganu31 March – 2 April 2006

MSO-HNS Newsletter Page 17

Volume 1, Issue 1

Page 18 MSO-HNS Newsletter

THYROID SYMPOSIUM FOR ENT SURGEONS

it is quite clear that more ENT

surgeons are entering the realm

of thyroid surgery. Participation

was truly encouraging with more

than 70 participants including

post-graduate students, young

surgeons and senior surgeons

as well. Good lectures ranging

from surgery in benign thyroid

disease, to managing neck

diseases in malignant thyroid

disease, complications in thyroid

surgerys well as thyroplasty and

laser cordectomy ware presented.

The finale was the comments

from the panel of experts whose

arguments definitely raised a

few eyebrows in the audience. The

debate as to who should do thyroid

surgery is still going on, but the

general consensus was if you are

trained for it then do it. Otherwise

let the experts handle it. On the

whole a well organized course

by Dr. Kuljit Singh and we look

forward to future courses in thyroid

diseases and surgery.

The participants attentively listening (must be interesting from the looksof it) to the lectures presented

Dr. Jeevanan Jahendran

Exco MSO-HNS

HEALTH CAMP AT PULAU REDANGDr. Jeevanan Jahendran

Exco MSO-HNS

a trip by boat to the various

surrounding islands where we

had great fun with snorkeling.

Though the deep water in certain

places got a little too scary for

some of us. After a wonderful

BBQ that night followed by a

lucky draw, we were all too tired

for anything else but the bed. The

next day before our final farewell,

a trip to the Marine park was

organized and it was good fun

with loads of fishes to be seen

whi le snorkel ing and some

friendly enough to actually take

food from your hands.

Congratulations to Dr. Amran

and his team for organizing a

wonderful and memorable event

for the members who made this trip.

Aural endoscopy being done byDr. Jeevanan with Dr. Harvinderlooking on and surrounded by

curious onlookers

Malaysian Society of

Otorhinolaryngologists

MSO-HNS Secretariat

19, Jalan Folly Barat,

50480, Kuala Lumpur.

Phone: 03-20930100

Fax: 03-20930900

E-mail:

[email protected]

We’re on the web! Visit

http://www.msohns.com!

Please direct all letters,

article submissions, picture

quizzes and suggestions to

The Editor,

Newsletter of the MSOHNS,

at the address above or to:

[email protected]

For the first time, a one day

symposium on thyroid disease

and surgery was organized by

the society for Otorhinolary-

ngologists and Surgeons at

the Hilton Kuala Lumpur on the

20th of November 2005. Invited

faculty included Professor Shahid

Hassan of USM, Dr. Zulkarnain

Hanaffi from Brunei Darussalam,

Dr Hisham Abdullah, Endocrine

Surgeon from Hospital Putrajaya,

Professor Abdullah Sani from

UKM and the organizing Chairman

Dr. Kuljit Singh of UMMC. The

domain of thyroid surgery has

always been in the hands of the

General Surgeon and the role of

the ENT surgeon thus far has

been the vocal cord assessment

pre-operatively and managing

the pa ra l yzed voca l co rds

following thyroid surgery. From

the response to the symposium

The MSO HNS annual Health

Camp was conducted this year

in Pulau Redang, Terengganu

under the able chairmanship of

Dr. Amran bin Mohamad together

w i th h is team f rom Hosp i ta l

Kuala Terengganu. A team of 20

ENT surgeons from all over the

country along with audiologists

and allied health personnel from

the Health Ministry of Terengganu

came together to participate in

this annual event.

The camp was held on the 1st of

April in the only primary school

on the island. Unfortunately the

men folk had gone to the sea so

we only managed to see a few

senior citizens, the ladies and

loads of kids with the usual

pediatric ENT problems. The kids

as usual were a curious lot and

were especially intrigued when

endoscopies were done. The

services of Dr. Hashim, (President’s

husband) an ophthalmologist

was truly appreciated as there

was a local outbreak of con-

junctivitis during our visit.

Hearing screening tests were

also performed and routine blood

pressure and b lood sugar

monitoring was done as well. Two

interesting tests were the body

fat density measurement and the

f i tness level measure were

favorites especially among the

well-endowed people who were

supposed to be conducting the

camp (I was one of them too).

After completing the camp, it was

time for the team to have its

recreational fun. This started with

Volume 1, Issue 1