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Duplicate internal auditory canals with facial and vestibulocochlear nerve dysfunction

Kew TY, Abdullah A

J Laryngol Otol, 2012 Jan;126(1):66-71.
PMID: 21867589 DOI: 10.1017/S0022215111002258

We report an extremely rare case of duplication of the internal auditory canal associated with dysfunction of both the facial and vestibulocochlear nerves. We also review the literature regarding the integrity of the facial and vestibulocochlear nerves in such cases.
Primary fungal laryngitis mimicking recurrent laryngeal carcinoma

Thomas RA, Kew TY, Mat Baki M

BMJ Case Rep, 2022 Feb 09;15(2).
PMID: 35140081 DOI: 10.1136/bcr-2021-245678

A 79-year-old smoker with a background history of a treated glottic carcinoma and chronic obstructive pulmonary disease presented with progressive hoarseness, symptoms of aspiration and shortness of breath for 6 months. Examination revealed an ulcero-fungating mass over the posterior commissure of the larynx. A tracheostomy, direct laryngoscopy and biopsy of the mass was performed to secure his airway and to exclude recurrent glottic carcinoma. Reassuringly, a histopathological examination of the mass revealed numerous fungal yeast bodies. He was then treated with itraconazole for 4 weeks and was followed up as and outpatient with complete resolution and no recurrence of the disease.
Retrospective analysis of the sonographic and computed tomographic features of gallbladder empyema

Zainal IA, Kew TY, Othman HA

Emerg Radiol, 2021 Nov 23.
PMID: 34811585 DOI: 10.1007/s10140-021-01996-1

OBJECTIVE: Early detection of complicated cholecystitis, particularly gallbladder empyema, is important. Yet only a handful of patients are correctly diagnosed prior to intervention. The purpose of this study was to evaluate the sonographic and computed tomography features associated with gallbladder empyema compared with the intraoperative findings and histopathological examination.
MATERIALS AND METHODS: We retrospectively reviewed ultrasound and CT images for 146 patients with clinical suspicion of cholecystitis from January 2013 until December 2018. Ultrasound criteria reviewed included calculus, wall thickening, pericholecystic fluid, gallbladder distension and presence of echogenic material within the gallbladder. For CT, criteria reviewed were wall thickening, gallbladder distension, mucosal enhancement, pericholecystic fluid and hyperdense bile with an attenuation value of more than 20 HU. Association of these findings was made with intraoperative and pathological findings of 85 patients with proven gallbladder empyema.
RESULTS: Sonographic signs that were statistically significantly associated with gallbladder empyema (p < 0.05) were thickened gallbladder wall (mean 5.4 versus 3.0 mm), distended gallbladder (mean 8.5 versus 6.4cm), pericholecystic fluid and echogenic material within the gallbladder. No significant association between gallstones and gallbladder empyema. Scores of two and more out of four significant sonographic findings were found to have an association with higher chances of developing gallbladder empyema (p < 0.05, odds ratio: 10). None of the CT features was found to be significant with gallbladder empyema (p > 0.05).
CONCLUSION: A combination of few ultrasound features has a high significant association with gallbladder empyema. Thus, in the proper clinical setting, these findings should alarm the sonographic operator on the possibility of gallbladder empyema.
Fulltext Communicating Hydrocephalus in a Case of Long-Term Primary Hyperparathyroidism

Ooi CP, Mustafa N, Kew TY

J ASEAN Fed Endocr Soc, 2018;33(1):49-52.
PMID: 33442110 DOI: 10.15605/jafes.033.01.08

We present the rare case of a 47-year-old woman with protracted primary hyperparathyroidism complicated by communicating hydrocephalus and cerebellar tonsillar herniation secondary to calvarial thickening. The parathyroid glands remained elusive, despite the use of advanced preoperative imaging modalities and three neck explorations. The serum calcium was optimally controlled with cinacalcet and alfacalcidol. Awareness of this rare complication is essential for early diagnosis and prompt intervention to prevent fatal posterior brain herniation.
Adenoid cystic carcinoma of the sinonasal tract: outcome of endonasal endoscopic surgery at five-year follow up

Gendeh BS, Zahedi FD, Ahmad H, Kew TY

J Laryngol Otol, 2013 May;127(5):511-5.
PMID: 23570560 DOI: 10.1017/S0022215113000480

To study the outcome of endonasal endoscopic surgery for adenoid cystic carcinoma of the sinonasal tract over a five-year follow-up period.
Sphenoethmoid sinusitis in a child resulting in a disastrous intracranial sequela

Sow AJ, Jahendran J, Toh CJ, Kew TY

Ear Nose Throat J, 2012 Nov;91(11):E20-2.
PMID: 23288800

Localized sphenoethmoid sinusitis in children is a rare occurrence. It is usually overlooked because of the misconception that the sinuses are not developed. We describe a case of localized acute sphenoid and right posterior ethmoid sinusitis that presented as right frontobasal subdural empyema and multiple deep cerebral abscesses. Morbidity from subdural empyema in children is high. Early diagnosis and treatment based on recognition that the etiology might involve the paranasal sinuses affects the overall prognosis.
Cochlear nerve canal stenosis and associated semicircular canal abnormalities in paediatric sensorineural hearing loss: a single centre study

Zainol Abidin Z, Mohd Zaki F, Kew TY, Goh BS, Abdullah A

J Laryngol Otol, 2020 Jul;134(7):603-609.
PMID: 32713375 DOI: 10.1017/S0022215120001334

OBJECTIVE: This study aimed to evaluate the association between cochlear nerve canal dimensions and semicircular canal abnormalities and to determine the distribution of bony labyrinth anomalies in patients with cochlear nerve canal stenosis.
METHOD: This was a retrospective study in which high-resolution computed tomography images of paediatric patients with severe-to-profound sensorineural hearing loss were reviewed. A cochlear nerve canal diameter of 1.5 mm or less in the axial plane was classified as stenotic. Semicircular canals and other bony labyrinth morphology and abnormality were evaluated.
RESULTS: Cochlear nerve canal stenosis was detected in 65 out of 265 ears (24 per cent). Of the 65 ears, 17 ears had abnormal semicircular canals (26 per cent). Significant correlation was demonstrated between cochlear nerve canal stenosis and semicircular canal abnormalities (p < 0.01). Incomplete partition type II was the most common accompanying abnormality of cochlear nerve canal stenosis (15 out of 65, 23 per cent).
CONCLUSION: Cochlear nerve canal stenosis is statistically associated with semicircular canal abnormalities. Whenever a cochlear nerve canal stenosis is present in a patient with sensorineural hearing loss, the semicircular canal should be scrutinised for presence of abnormalities.
Fulltext Pseudomonas laryngeal perichondritis: unexpected diagnosis

Zainal Abidin SS, Kew TY, Azman M, Mat Baki M

BMJ Case Rep, 2020 Dec 22;13(12).
PMID: 33370978 DOI: 10.1136/bcr-2020-237129

A 57-year-old male chronic smoker with underlying diabetes mellitus presented with dysphonia associated with cough, dysphagia and reduced effort tolerance of 3 months' duration. Videoendoscope finding revealed bilateral polypoidal and erythematous true and false vocal fold with small glottic airway. The patient was initially treated as having tuberculous laryngitis and started on antituberculous drug. However, no improvement was observed. CT of the neck showed erosion of thyroid cartilage, which points to laryngeal carcinoma as a differential diagnosis. However, the erosion was more diffuse and appeared systemic in origin. The diagnosis of laryngeal perichondritis was made when the histopathological examination revealed features of inflammation, and the tracheal aspirate isolated Pseudomonas aeruginosa The patient made a good recovery following treatment with oral ciprofloxacin.
Fulltext Intracavernous internal carotid artery pseudoaneurysm

Sridharan R, Low SF, Mohd MR, Kew TY

Singapore Med J, 2014 Oct;55(10):e165-8.
PMID: 25631906

Epistaxis is commonly encountered in otorhinolaryngologic practice. However, severe and recurrent epistaxis is rarely seen, especially that originating from a pseudoaneurysm of the intracavernous internal carotid artery (ICA). We herein present the case of a 32-year-old man who was involved in a motor vehicle accident and subsequently developed recurrent episodes of profuse epistaxis for the next three months, which required blood transfusion and nasal packing to control the bleeding. Computed tomography angiography revealed a large intracavernous ICA pseudoaneurysm measuring 1.7 cm × 1.2 cm × 1.0 cm. The patient underwent emergent four-vessel angiography and coil embolisation and was discharged one week later without any episode of bleeding. He remained asymptomatic after three-month and one‑year intervals. This case report highlights a large intracavernous ICA pseudoaneurysm as a rare cause of epistaxis, which requires a high index of suspicion in the right clinical setting and emergent endovascular treatment to prevent mortality.
Fulltext Recurrent Temporal Infections: The Link to Systemic Lupus Erythematosus

Shuhardi SA, Mohamed Said MS, Kew TY, Ramli R

Am J Case Rep, 2023 Dec 29;24:e942163.
PMID: 38155491 DOI: 10.12659/AJCR.942163

BACKGROUND Systemic lupus erythematosus (SLE) is an autoimmune disease with diverse manifestations. The involvement of the musculoskeletal system is very common, and infection is one of the manifestations, which can involve any part of the body. We report a case of a middle-aged woman with recurrent episodes of infection of her left temple. CASE REPORT A 51-year old woman was referred to our clinic following failures to eradicate infection on her left temple for 9 months. Examination revealed facial asymmetry, with diffuse non-tender swelling involving her left temple area, which extended to her cheek. Computed tomography and magnetic resonance imaging (MRI) showed a periosteal reaction of the zygomatic bone. Left temporalis muscle thickening and residual osteomyelitis of the zygomatic bone were also shown by MRI. In view of the unresolved infection with incision and drainage and antibiotics, further blood investigations led to the discovery of SLE. The antinuclear antibody and anti-double-stranded DNA were positive. In addition, low nephelometry markers, C3 (26.7 mg/dL) and C4 (8.24 mg/dL), were observed. This patient was treated with 200 mg of oral hydrochloroquine once daily and 5 mg of oral prednisolone once daily. After 6 months of treatment, the infection subsided, and the structures involved showed remarkable healing. The patient is still taking the same dose and frequency of both drugs at the present time. CONCLUSIONS Temporalis pyomyositis and osteomyelitis of the zygomatic bone could be manifestation of SLE disease; however, the involvement of infection cannot be ruled out.
Fulltext A Rare Case of Basal Cell Adenocarcinoma of Parotid Gland with Intracranial Extension

Razali MN, Mat Baki M, Kew TY, Mohamad Yunus MR

Indian J Otolaryngol Head Neck Surg, 2019 Oct;71(Suppl 1):93-95.
PMID: 31741939 DOI: 10.1007/s12070-017-1116-3

Basal cell adenocarcinoma (BCAC) is a rare tumour entity. Despite its tendency to be infiltrative and destructive tumour with propensity to recur, it rarely metastasizes and long-term outcome following surgery is favourable. This paper presents a 42-year-old male with residual BCAC of parotid gland that had extended into infratemporal fossa and intracranial. The important aspect of this case is the rarity occurrence of BCAC of parotid with intracranial extension and its surgical approaches to achieve tumour clearance.
Fulltext 'Houdini's Pituitary:' A Case Report of Regression of Pituitary Mass to Empty Sella in a 58-Year-Old Man with Autoimmune Hypophysitis

Ooi CP, Kamarruddin NA, Mustafa N, Kew TY

J ASEAN Fed Endocr Soc, 2018;33(1):69-73.
PMID: 33442114 DOI: 10.15605/jafes.033.01.12

A 58-year-old male presented with persistent severe headache, lethargy, decline libido and no neurological deficits. Besides quadruple anterior pituitary hormonal deficiencies, magnetic resonance imaging (MRI) demonstrated an enlarged ring-enhanced non-homogenous pituitary. Following hormonal replacement, these symptoms improved but empty sella evolved. The challenges of diagnosis and management were discussed. Awareness of the unclear etiology and uncertain clinical course of autoimmune hypophysitis in a man in this age group is essential for prompt and appropriate management.
Fulltext Isolated blunt lingual artery injury secondary to a road traffic accident: diagnostic and therapeutic approach

Mawaddah A, Goh BS, Kew TY, Rozman Z

Malays J Med Sci, 2012 Apr;19(2):77-81.
PMID: 22973141 MyJurnal

Neurologic and airway compromise as a result of traumatic vascular injuries to the neck region often lead to more severe complications and thus require special consideration. Furthermore, these cases pose diagnostic and therapeutic challenges to healthcare providers. Here, we report a case of a 28-year-old motorcyclist presenting with progressively enlarged Zone 2 neck swelling on the left side following a high impact collision. There were no symptoms or signs suggesting neurologic or laryngeal injury. Computed tomography angiogram of the neck revealed signs of an active arterial bleed. The apparent vascular injury was managed by close observation for signs of airway compromise, urgent angiogram, and selective catheter embolisation of the left lingual artery. The patient subsequently recovered without further operative exploration of the neck. At 6 months post-trauma, the neck swelling fully subsided with no complications from angioembolisation. This case illustrates the individualised treatment and multidisciplinary approach in managing such cases. We review our rationale for this diagnostic and therapeutic approach.
Fulltext Non Secretory Multiple Myeloma With Extensive Extramedullary Plasmacytoma: A Diagnostic Dilemma

Low SF, Mohd Tap NH, Kew TY, Ngiu CS, Sridharan R

Iran J Radiol, 2015 Jul;12(3):e11760.
PMID: 26528383 DOI: 10.5812/iranjradiol.11760v2

Multiple myeloma (MM) is characterized by progressive proliferation of malignant plasma cells, usually initiating in the bone marrow. MM can affect any organ; a total of 7 - 18% of patients with MM demonstrate extramedullary involvement at diagnosis. Non-secretory multiple myeloma (NSMM) is a rare variant that accounts for 1 - 5% of all cases of multiple myeloma. The disease is characterized by the absence of monoclonal gammopathy in serum and urine electrophoresis. Our case report highlights the diagnostic challenge of a case of NSMM with extensive extramedullary involvement in a young female patient who initially presented with right shoulder pain and bilateral breasts lumps. Skeletal survey showed multiple lytic bony lesions. The initial diagnosis was primary breast carcinoma with osseous metastases. No monoclonal gammopathy was found in the serum or urine electrophoresis. Bone marrow and breast biopsies revealed marked plasmacytosis. The diagnosis was delayed for a month in view of the lack of clinical suspicion of multiple myeloma in a young patient and scant biochemical expression of non-secretory type of multiple myeloma.
Fulltext CT findings of congenital neonatal pyriform aperture stenosis

Sidek HAB, Teh YG, Tangaperumal A, Zaki FM, Kew TY

Oxf Med Case Reports, 2021 May;2021(5):omab018.
PMID: 34055355 DOI: 10.1093/omcr/omab018

Congenital neonatal pyriform aperture stenosis (CNPAS) is a rare but potentially lethal condition that causes respiratory distress. The characteristic narrowing of the pyriform aperture along with other associated craniofacial dysmorphism is diagnosed using cross-sectional imaging such as computed tomography (CT) and magnetic resonance imaging. CT scan is the imaging of choice for confirming and characterizing CNPAS. Infants are obligate nasal breathers in the first 5 months of life. Hence, a high degree of clinical suspicion, prompt imaging diagnosis and adequate respiratory support is critical to help reduce the morbidity of this condition.
Fulltext Mastoid Abscess in a Child With Eustachian Tube Dermoid Cyst

Mohd Zulkefli NA, Abdullah A, Hashim ND, Nasseri Z, Kew TY

Cureus, 2021 May 30;13(5):e15326.
PMID: 34221773 DOI: 10.7759/cureus.15326

A dermoid cyst (DC) is a benign tumor caused by inclusion errors during embryogenesis. DC of the head and neck is a well-recognized entity both clinically and histologically; however, it rarely occurs in the Eustachian tube (ET). Due to its anatomical position, significant morbidity related to middle ear dysfunction may result from ET obstruction. In this report, we present a rare case of a girl child aged two years and nine months with persistent otorrhea, who was initially diagnosed with acute otitis media with mastoiditis, along with suspicion of congenital cholesteatoma. However, high-resolution CT (HRCT) temporal and MRI of the neck revealed a DC of the ET causing left chronic otitis media (COM) with mastoid abscess. The patient underwent mastoid exploration surgery and myringotomy with grommet insertion. Although complete excision is the standard treatment modality for DC, the treatment of poorly ventilated mastoid and middle ear takes precedence over it. MRI surveillance scan is recommended in such cases.
A proposal for needle projections in transcutaneous injection laryngoplasty using three-dimensionally reconstructed CT scans

Nasir ZM, Azman M, Baki MM, Mohamed AS, Kew TY, Zaki FM

Surg Radiol Anat, 2021 Aug;43(8):1225-1233.
PMID: 33388863 DOI: 10.1007/s00276-020-02639-9

PURPOSE: This study aims to determine laryngeal dimension in relation to all three transcutaneous injection laryngoplasty (TIL) approaches (thyrohyoid, transthyroid and cricothyroid) using three-dimensionally reconstructed Computed Tomography (CT) scan and compare the measurements between sex, age group and ethnicity.
METHODS: CT scans of the neck of two hundred patients were analysed by two groups of raters. For thyrohyoid approach, mean distance from the superior border of the thyroid cartilage to the laryngeal cavity (THd) and mean angle from the superior border of the thyroid cartilage to mid-true cords (THa) were measured. For transthyroid approach, mean distance from mid-thyroid cartilage to mid-true cords (TTd) and Hounsfield unit (HU) at mid-thyroid cartilage (TTc) were measured. For cricothyroid approach, mean distance from the inferior border of the thyroid cartilage to the laryngeal cavity (CTd) and mean angle from the inferior border of the thyroid cartilage to mid-true cords (CTa) were measured.
RESULTS: There were statistically significant differences between males and females for all measurements except for CTa (p 0.05). There was a significant fair positive correlation between age and TTc (p = 0.0002). For all measurements obtained, there were moderate to excellent inter-group consistency and intra-rater reliability.
CONCLUSION: This study demonstrated a significant sex dimorphism that may influence the three TIL approaches except for needle angulation in the cricothyroid approach. The knowledge of laryngeal dimension is important to increase success in TIL procedure.
Fulltext Volumetric evaluation of the sphenoid sinus among different races in the Southeast Asian (SEA) population: a computerized tomography study

Tuang GJ, Zahedi FD, Husain S, Hamizan AKW, Kew TY, Thanabalan J

Int J Med Sci, 2023;20(2):211-218.
PMID: 36794158 DOI: 10.7150/ijms.68095

Introduction: The fundament of forensic science lies in identifying a body. The morphological complexity of the paranasal sinus (PNS), which varies greatly amongst individual, possess a discriminatory value that potentially contributes to the radiological identification. The sphenoid bone represents the keystone of the skull and forms part of the cranial vault. It is intimately associated with vital neurovascular structures. The sphenoid sinus, located within the body of the sphenoid bone, has variable morphology. The sphenoid septum's inconsistent position and the degree, as well as the direction disparities of sinus pneumatization, have indeed accorded it a unique structure in providing invaluable information in forensic personnel identification. Additionally, the sphenoid sinus is situated deep within the sphenoid bone. Therefore, it is well protected from traumatic degradation from external causes and can be potentially utilized in forensic studies. The authors aim to study the possibility of variation among the race, and gender in the Southeast Asian (SEA) population, using volumetric measurements of the sphenoid sinus. Materials and methods: This is a retrospective cross-sectional analysis of computerized tomographic (CT) imaging of the PNS of 304 patients (167 males, 137 females) in a single centre. The volume of the sphenoid sinus was reconstructed and measured using commercial real-time segmentation software. Result: The total volume of sphenoid sinus of male gender had shown to be larger, 12.22 (4.93 - 21.09) cm3 compared to the counterpart of 10.19 (3.75 - 18.72) cm3 (p = .0090). The Chinese possessed a larger total sphenoid sinus volume, 12.96 (4.62 - 22.21) cm3) than the Malays, 10.68 (4.13 - 19.25) cm3 (p = .0057). No correlation was identified between the age and volume of the sinus (cc= -.026, p = .6559). Conclusion: The sphenoid sinus volume in males was found to be larger than those of females. It was also shown that race influences sinus volume. Volumetric analysis of the sphenoid sinus can potentially be utilized in gender and race determination. The current study provided normative data on the sphenoid sinus volume in the SEA region, which can be helpful for future studies.
Fulltext Cat Scratch Disease-A Benign Disease with Thymic Hyperplasia Mimicking Lymphoma

Leong MH, Nabillah MJ, Rizuana IH, Asma A, Kew TY, Tan GC

Diagnostics (Basel), 2023 Jul 24;13(14).
PMID: 37510201 DOI: 10.3390/diagnostics13142457

Cat scratch disease (CSD) is a benign condition caused by the inoculation of Bartonella henselae. The imaging findings are non-specific, and it is difficult to diagnose the disease via imaging. However, imaging studies help exclude other differential diagnoses in diagnostic dilemmas. We encountered a case of a 17-year-old adolescent who presented with painful neck swelling. CT showed multiple bilateral cervical lymphadenopathies with triangular soft tissue mass at the anterior mediastinum likely to be thymic hyperplasia, which is unusual in CSD and was mistaken for a lymphoproliferative disorder. Tissue diagnosis with a thorough clinical history yielded the diagnosis of cat scratch disease, and follow-up imaging showed resolution of the cervical lymphadenopathy and thymic hyperplasia.
Exploring Skull Base Osteomyelitis: Comprehensive Case Reports and Management Strategies

Rosdi NF, Abdullah A, Kew TY, Maktar JF, Lokman FL

Cureus, 2024 Jan;16(1):e51973.
PMID: 38333479 DOI: 10.7759/cureus.51973

Skull base osteomyelitis is a not commonly encountered but potentially fatal consequence of untreated necrotizing otitis externa. Early recognition and appropriate treatment are crucial to prevent serious complications such as cranial nerve palsies, meningitis, and intracranial abscess formation. The case reports presented in this study provide a rich depiction of the clinical presentation, diagnostic challenges, and interventions employed. Early recognition and appropriate management of skull base osteomyelitis are crucial to prevent complications and improve patient outcomes.

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