Short Note 2005

-A fistula is an abnormal communication between two epithelialized surfaces.

-Pharyngocutaneous fistula is the most common non-fatal complication following total laryngectomy.

– It creates a communication between the pharynx and cervical skin around the surgical incision or, less frequently, the stoma of the tracheostomy.

– Billroth was also the first person to report PCF as one of the complications of total laryngectomy (he performed first total laryngectomy)

– INCIDENCE reported extremely variable ranging from 3.6% to 65%


-Total laryngectomy w or w/o pharyngectomy
-Partial laryngectomy
-Commando procedure



-a complication that appears in the early post-operative period after total laryngectomy.

-Usually around 3th to 8th post operative day.

-Pharyngeal contents, usually saliva, flow through the fistula emerging from the cutaneous orifice

– Mean hospitalization time is usually 13 – 15 days in comparison to 3 – 5 days for other patients.

-increased morbidity, delay in adjuvant treatment, prolonged hospitalization, and high treatment costs

-More common in males than females



  1. Time of oral feeding Initiating oral feeding within 48 hours of total laryngectomy without partial pharyngectomy; who have not had a previous surgical resection of the upper aerodigestive tract; and who have either not received previous therapeutic irradiation to the head and neck region; does not increase the frequency of PCF. Oral feeding especially with solid food encourages granulation tissue formation along the fistula tract and eventually results in more spontaneous closure of the fistula tract.
  2. Age – > 60 yrs more predisposed.
  3. Gastroesophageal reflux disease(GORD) Prophylactic use of ranitidine (H2 receptor blocker) and metoclopramide (prokinetic) has decreased the incidence of pharyngo-cutaneous fistula
  4. Preoperative tracheostomy contributes to post total laryngectomy PCF fistula formation
  5. Tumor stage and laryngeal site Glottis Ca > Supraglottis > Pyriform sinus > Subglottis
  6. Preoperative Hb:  Low preoperative Hb increases the incidence of PCF nine-fold
  7.  Preoperative radiation: Related to increase of the radiation field size, dose increment and a change from continuous to fractionated radiation therapy 8. Malnutrition
  8. Suture material: There is a statistically significant difference in the formation of PCF between vicryl and catgut groups in favor of vicryl which has greater tensile strength, less inflammatory reaction and has a longer half- life Staples have shown a much lesser incidence of PCF
  9. Positive surgical margins: Presence of infiltrated margins may explain the higher frequency of fistula formation as a result of deficient healing process occurring at the surgical wound, where the presence of the tumor cells may negatively influence the healing process and wound closure. 11. Vascular diseases related to smoking and alcohol drinking


Early diagnosis is important:
Less risky for sepsis and major vessel rupture
More conservative and easy management
Early sign of impending Pharyngocutaneous fistula:
Persistent low-grade fever: 38.5C
wound erythema and edema
localized tenderness in central neck near the wound
wound infection unresponding to conservative treatment
saliva seen at wound or in the drain tube
esophagogram: sinus tract> 2 cm
barium methyl blue swallowing test (+)
definitive fistula formation
Conservative management:
Residual tumor should be excluded firstly
Surgical intervention is reserved when failed by Conservative management
Saliva accumulation ->abscess formation ->flap necrosis and sepsis
Goal: infection control and prevention of large fistula
If suction drain tube (+), delay removal or shift to penrose for drainage
If no drain tube:
Small: Repeated aspiration
Large with abscess formation: open drain:
Away from the stoma: prevention of aspiration
Temporal pharyngostoma-> secondary reconstruction
Silicone septal button with stoma bag (khan 1993)
Removal and curettage of necrotic tissue
Pressure dressing for flap down
Tube feeding with adequate nutrition
Infection control: systemic antibiotics: aerobic and anaerobic.
Time: small fistula without infection< 2-3 weeks
Most: less than 40 days
Surgical management:

PCF have been classified according to source of tissue used in reconstruction to three types:
Type I: two layers are repaired locally
Type II: one locally, one distantly
Type III: both layers repaired distantly
Surgical options:
Direct primary closure: 2 layer: inner mucosa and outer skin
Reconstruction methods with local flap and free flap
Local adjacent flap:
Myocutaneous flaps

The pectoralis major flap offers the benefit of an excellent vascular pedicle.

The latissimus dorsi and the trapezius flaps much less advantageous than the versatile, durable pectoralis major.

Muscle flaps Sternocleidomastoid muscle flap is also used for fistula closure which has advantages of workable mass, good coverage and single stage reconstruction.
Free flap:
Forearm flap
Jejunal free graft


Short Note 2003



Procedure whereby  fistula of the lacrimal sac into the nasal cavity is created.

The operative approach to the sac may be external or endoscopic. The latter approach may use rigid telescopes or the microscope.



Endonasal approach to correct nasolacrimal obstruction was described way back in 1800 by Caldwell, West and later during the begining of 1900 by Mosher.

McDonogh was the first to perform endoscopic dacryocystorhinostomy in 1989.



  • Socially unacceptable epiphora caused by anatomic or functional lacrimal sac or nasolacrimal duct obstruction
  • Chronic dacryocystitis with purulent drainage from the canaliculi
  • Inflammation of the skin overlying the lacrimal sac in the region of the medial canthus
  • Dacryolith formation
  • Benign lacrimal sac mass


Advantages of endoscopic DCR:

  • better aesthetic result , no external scar.
  • any concomittant intranasal pathology causing epiphora can be addressed
  • avoids injury to the medial canthus and/or pathologic scar formation.
  • preserves the pumping mechanism of the orbicularis oculi muscle.
  • active infection of the lacrimal system is not a contraindication to surgery.
  • It is especially superior to the external approach in revision surgery.
  • less bloody than the external approach.
  • the perioperative time is shorter.
  • success rate is comparable to the external approach.


Disadvantages of endoscopic DCR:

  • It requires specialized training in nasal endoscopic surgery.
  • The endoscopic equipment is an expense.


Contraindications of endoscopic DCR:
–  Presence of a firm indurated mass above the level

of medial canthus.
–  Bloody epiphora
–  Presence of bony destruction as seen in

radiological films
–  Pseudoepiphora: is essentially reflux tearing: the

main gland over compensates secretion because

of lack of secretion from minor glands of along the

lid margin.


Surgery technique:

– Patient under GA

– Nasal packing with decongestants

– Localisation of lacrimal sac:  the anterior portion of middle turbinate, the sac lies just lateral to it.  The lacrimal fossa is bounded by the anterior lacrimal crest, which consists of the frontal process of the maxillary bone. The posterior lacrimal crest is made up of the lacrimal bone itself.

– Mucosal incision:  lateral wall mucosa is incised with a sickle knife and is elevated using a Freer elevator.  The incision is made vertically from inferior to superior.  After elevation the mucosa is removed using a Blakesley forceps.

– Bone removal:  To expose the lacrimal sac, the bony lacrimal fossa must be uncovered first.  Bone removal can be performed using a Kerrison’s punch forceps or by using a burr.

– Opening of lacrimal sac:  After overlying bone removal the lacrimal sac can be incised using a sickle knife.  An assistant could tent out the medial wall of the sac with lacrimal probes introduced through the canaliculi.  The whole of the medial wall of the sac is removed.

– Topical mitomycin can be applied to the site of surgery to prevent restenosis of the sac.




  • Instil one drop of fluorescein into the conjunctival sac
  • Put a cotton bud soaked in anaesthetic in the inferior meatus.
  • If fluorescein is detected after five minutes, the system is patent (positive Primary Jones Test)
  • If no fluorescein is discovered, this is a negative Primary Jones Test and the functional obstruction could be anywhere from the punctum to the Valve of Hasner.
  • Next, wash the excess fluorescein from the conjunctival sac and syringe. If fluorescein is detected, then this shows it had entered the sac and constitutes a positive Secondary Jones Test and suggests a functional obstruction of the nasolacrimal duct.
  • If no dye is found on the cotton bud after syringing, this is termed a negative Secondary Jones Test, because fluorescein had not entered the sac and, thus, there is stenosis of the puncta or canalicular system.
  • If no saline appears in the nose, there is a complete obstruction somewhere in the lacrimal drainage system.


Hard stop

If the cannula touches the medial wall of the lacrimal sac and lacrimal bone, a definite end point is reached. It indicates that there is no complete obstruction in the canalicular system


Soft stop

If a spongy end point is felt, this indicates that the cannula has been prevented from entering the lacrimal sac. Therefore, there is a blockage in the canalicular system and there will be no distension of the lacrimal sac when the plunger is pressed.



A.K.A: Adamantinoma of the jaw  ( Short Note 2003 )


Benign, locally aggressive tumours that arise from the mandible, or less commonly from the maxilla.



Ameloblastomas are the second most common odontogenic tumour (odontoma is the most common)

3rd to 5th decades of life

No gender predilection


Clinical presentation:

Hard painless slow growing mass near the angle of the mandible in the in the region of the 3rd molar tooth (48 and 38)

Can occur anywhere along the alveolus of the mandible (80%) and maxilla (20%).

When the maxilla is involved, the tumour is located in the premolar region, and can extend up in the maxillary sinus.

Although benign, it is a locally aggressive neoplasm with a high rate of recurrence. Approximately 20% of cases are associated with dentigerous cysts and unerupted teeth.



Arise from  ameloblasts, which are part of the odontogenic epithelium, responsible for enamel production and eventual crown formation.


Three variants are described:

simple (no nodule): best prognosis

luminal: single nodule projecting into the cyst

mural: multiple nodules (often only microscopic) in the wall of the cyst


Radiographic features

Plain film and CT

It is classically seen as a multiloculated (80%), expansile “soap-bubble” lesion, with well demarcated borders and no matrix calcification.


In general ameloblastomas demonstrate a mixed solid and cystic pattern, with a thick irregular wall, often with papillary solid structures projecting into the lesion.


Treatment and prognosis

surgical en-bloc resection.

Local curettage is associated with a high rate of local recurrence (45-90%).

Simple unicystic lesions are less common but have a better prognosis. Simple (no nodule) variant will not be diagnosable on radiography, as it will be indistinguishable form other more common cysts. Luminal variant, has a single nodule projecting into the cyst.

Mural variant has multiple nodules (often only microscopic) in the wall of the cyst. has an elevated risk of recurrence.



Malignant behaviour is seen in two forms :

  1. ameloblastic carcinoma
  • frankly malignant histology
  1. malignant ameloblastoma
  • metastases despite well differentiated ‘benign’ histology


Differential diagnosis

  1. dentigerous cyst: the relationship between ameloblastomas and dentigerous cysts is a controversial one, 20% of ameloblastomas thought to arise from pre-existing dentigerous cysts
  2. odontogenic keratocyst (OKC): usually unilocular with thin poorly enhancing walls
  3. odontogenic myxoma: can be almost indistiguishable
  4. aneurysmal bone cyst (ABC)
  5. fibrous dysplasia


Short Note 2003



  • Formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart.



Usually from a spreading infection in the nose, sinuses, ears, or teeth.

Nasal furuncle (50%), sphenoidal or ethmoidal sinuses (30%) and dental infections (10%).

Less common primary sites of infection include tonsils, soft palate, middle ear, or orbit (orbital cellulitis).

The highly anastomotic venous system of the paranasal sinuses allows retrograde spread of infection to the cavernous sinus via the superior and inferior ophthalmic veins (valveless veins).

Causative organism: Staphylococcus infectious 70% of the cases. Streptococcus is the second leading cause. Gram-negative rods and anaerobes, rarely Aspergillus fumigatus and mucormycosis.







-abrupt onset of unilateral periorbital edema, headache,

photophobia and proptosis

– Ptosis, chemosis, cranial nerve palsies (III, IV, V,VI).

Sixth nerve palsy is the most common. ( it is the content of cavernous sinus while others are located at lateral wall)

– Sensory deficits of the ophthalmic and maxillary branch of the fifth nerve are common.

– Periorbital sensory loss and impaired corneal reflex

– Papilledema, retinal hemorrhages, and decreased visual acuity and blindness may occur from venous – congestion within the retina.

– Fever, tachycardia and sepsis may be present.

– Headache with nuchal rigidity may occur.

– Pupil may be dilated and sluggishly reactive.

– Infection can spread to contralateral cavernous sinus within 24–48 hours of initial presentation.



FBC, ESR, blood cultures, and sinus cultures

Lumbar puncture TRO meningitis.

CT BRAIN/ PNS: Opacification, sclerosis, and air-fluid levels, thickening of the superior ophthalmic vein, and irregular filling defects within the cavernous sinus.

MRI,  MR venogram : more sensitive than a CT scan & imaging studies of choice. Findings may include deformity of the internal carotid artery within the cavernous sinus, and an obvious signal hyperintensity within thrombosed vascular sinuses on all pulse sequences.





  • IV Antibiotics: IV Rocephine 2g OD

+/-  IV Metronidazole 500mg TDS

  • Anticoagulation with heparin is controversial.
  • Steroid therapy is also controversial.


Surgical drainage with sphenoidotomy is indicated if the primary site of infection is thought to be the sphenoidal sinuses.


All patients with CST are usually treated with prolonged courses (3–4 weeks) of IV antibiotics. If there is evidence of complications such as intracranial suppuration, 6–8 weeks of total therapy may be warranted.



Laryngeal surgery

Classification of laryngeal surgery:

Divided into endoscopic and open techniques. Open techniques divided into expansion and resection.

  • Endoscopic:
  1. Dilatation – bougie, balloon
  2. LASER: shapshay
  3. Cold instrumentation
  • Open:


  1. LTR 
  • Anterior split
  • Posterior split
  • Antero posterior split
    Put costal cartilage graft for expansion or tracheal mucosal flap


  1. Cricotracheal resection and anastomoses (CTRA)
  2. Tracheal resection and anastomoses (TRA)

T tube

Why T tube is better than Shilley tube? 

  • Self cleansing
  • Stent the upper limb of segment

Immediate Complications of Post Operative TRA

  1. Anastomotic leak —> subcutaneous emphysema
  2. Hematoma
  3. Pneumon
  4. Local infection – SSI, hemorrhage
  5. DVT

Other complications:

  1. Recurrent stenosis
  2. Laryngeal dysfunction causing VC palsy (50% temporary) 

Contraindications of TRA:

  • Less than 1cm from VC (in children between 3mm to 5mm)
  • Length of stenosis >4cm (must have adequate trachea for anastomoses) 
  • Tracheomalacia
  • Multilevel stenosis
  • Previous RT 
  • Failed larynhotracheal reconstruction before
  • Poor pulmonary function – assess single breath counting, PEFR, FEV1
  • Debilitating medical illnesses- COAD, uncontrolled DM
  • Vocal cord immobility 

Prognosis of surgery depends on

  • Age
  • Comorbid
  • Site of stenosis: Subglottic stenosis, trachea stenosis
  • Grade of obstruction – CM grading 
  • Length of stenosis 
  • Tracheomalacia
  • Presence of tracheostomy at time to resection 
  • Presence of 2′ airway pathology 
  • VC – normal mobility or impaired
  • Obese, thick neck, neck circumference —> increase complications 

Stenting in larynx:

  • Stable larynx ie: expansion with anterior graft doesn’t need stent
  • Unstable larynx ie: expansion with anteroposterior graft needs stent
  • Stent causes granulation tissue so must aim to take out by 6 weeks
  • Types of stents: Rubber stent, LTMOLD stent

Bougie vs Balloon dilatation:


  • Free , not costly
  • Shearing force –> increase reformation of stenosis due to scarring ( not good)

Balloon: RM1k ++

  • Expensive
  • Radial force –> less epithelial injury, less scar contraction (good)


Definition of Leukoplakia:

  • Premalignant condition
  • Characterised by a white patch or plaque that cannot be characterized clinically or histologically as any other disease. (WHO Definition)
Picture from:
Picture from:

How does Verrucous Carcinoma differ from SCC?

Verrucous Carcinoma: “Ackerman’s tumor.”  – 1st described by Ackerman

  • Uncommon variant of SCC, locally aggressive, clinically exophytic, low-grade, slow-growing, well-differentiated squamous cell carcinoma with minimal metastatic potential.
  • Risk factors: tobacco chewing,  oral snuff  “Snuff dipper’s cancer”, smoking, alcohol, betel nut chewing
  • Good prognosis. Local recurrence is not uncommon, but metastasis to distant parts of the body is rare.
  • Painless, thick white plaque resembling a cauliflower (warty lesion)
  • Commonest site: Oral cavity
  • Treatment: Wide local excision or radiotherapy

Cholesteatoma (Part 2)



Cyst like structure in ME cleft that contains pale debris


  • Fully differentiated stratified keratinizing squamous epithelium (capsule/ matrix)
  • A nuclear keratin squamous epithelium (core)
  • Epidermal Langerhans cells
  • FB granuloma/ FB Giant cells
  • Polyps
  • Granulation tissue

How does squamous epithelium in cholesteatoma differs from skin? [viva]

  • Absence of skin appendages ( glands/ hair follicles)

Different types of operation for cholesteatoma: 

Canal wall up procedure :

  • Atticotomy
  • Atticoantrostomy
  • Cortical mastoidectomy
  • Combined approach tympanoplasty

Canal wall down procedure :

  • Modified radical mastoidectomy
  • Radical mastoidectomy

Causes of persistent ear discharge post mastoidectomy:

  • Infection
  • Residual
  • Recurrence
  • High facial ridge
  • Granulation tissue/ mastoid cavity not well epithelialized

Sites of residual cholesteatoma/ difficult areas of cholesteatoma:

  1. Facial recess
  2. Sinus tympani – area medial to facial nerve.

To overcome: also do anterior tympanotomy for better access.

  1. Sinodural angle
  2. Mastoid tip
  3. Zygomatic root
  4. Anterior epitympanum – due to head of malleus blocking the view (posterior tympanotomy access)

Difficulty/problem in Down syndrome:

  1. Atlantoaxial dislocation
  2. Heart disease
  3. Short neck, macroglossia – difficult in anaesthesia
  4. Narrow airway, reduced tone

Why do Down’s syndrome have persistent discharging ear?

  1. Unable to complain
  2. Small EAC
  3. ET dysfunction – patulous ET ( no angle)
  4. A/w cleft lip and palate
  5. Difficult to cooperate for ear toilet and examination 


Definition: (Abramson et al, 1977)

Points to mention: [viva]

  • 3 dimensional epidermal and connective tissue structure
  • Forming a sac
  • Conforming the middle ear cleft ( middle ear, attic, mastoid)
  • Capacity for progressive and independent growth involving the underlying bone and replacing the middle ear mucosa
  • Tendency to recur



  1. Congenital
  2. Acquired
  • Primary (no previous h/o ear infection)
  • Secondary (previous h/o  ear infection)

Congenital cholesteatoma aka: epidermoid cyst


Squamous epithelial cyst that can arise anywhere within the temporal bone


  1. White mass medial to TM
  2. Normal pars tensa and pars flaccida
  3. No history of otorrhea or perforation
  4. No history of previous ear surgery
  5. Prior bouts of OM not ground for exclusion

Theories for development of Cholesteatoma (6) [viva]

  1. Congenital cell rests ~ epidermoid formation in the anterior epitympanic area in the developing fetal middle ear
  2. Metaplasia of middle ear epithelium ~ squamous cell metaplasia in the ME epithelium in patients with cholesteatoma
  3. Papillary ingrowth through an intact TM at the Prusak space.

Why Prusak space? Answer: Poor ventilation in the area.

4. Invagination of epithelium through pre-existing retraction  pocket or perforation

– most widely accepted theory

– obstruction of Eustachian tube causing impaired ME ventilation —> TM retracted and forming retraction pocket. Continuous desquamation and keratin accumulation leads to cholesteatoma formation.

5. Implantation theory

– iatrogenic: grommet insertion/ Tympanoplasty –> implantation of squamous cell into ME

6. Epithelial invasion theory

– invasion of skin from meatal wall through marginal or attic perforation

Management of attic cholesteatoma [viva]

– able to see fundus: conservative management / ear toileting

– not able to see fundus: do PTA and HRCT

PTA shows >40dB HL: possible ossicular chain involvement

HRCT : anatomical/ surgical landmark & disease extent

  • Mastoid pneumatization – well pneumatization/ sclerotic
  • Facial nerve dehiscence
  • Ossicular disruption/ erosion
  • Tegmen tympani/mastoidea breach
  • Lateral SCC erosion

*** pictures are not mine. I googled them.

43rd UKM Temporal Bone Dissection Course 2015

On 22nd till 24th April 2015 I attended the 43rd UKM Temporal Bone DIssection Course 2015. This course is intended for otolaryngologists and residents/fellows in training to learn more about the temporal bone anatomy, related diseases and the management and also applied surgical techniques.

The venue of this course took place at the HUKM ORL Dept Level 9. The price was RM1000. That was quite a lot of money although luckily I managed to find sponsor.

Topics covered:

  • Anatomy of the temporal bone
  • Surgery for chronic ear disease
  • Conductive hearing loss
  • Surgery for otosclerosis
  • Sensorineural hearing loss
  • Cochlear implants
  • Acoustic neuroma
  • Surgery for acoustic neuroma

Procedures demonstrated and performed:

  • Cortical mastoidectomy
  • Endolymphatic sac decompression
  • Facial nerve identification
  • Stapes surgery
  • Canal wall down mastoidectomy
  • Cochlear implant
  • Labyrinthectomy
  • Translabyrinthine approach to the skull base

Overall I think this course was really beneficial for my learning. I was so caught up drilling the temporal bone that I almost always ended up didn’t realize how fast the time past. I wish we were given more time 🙂

Me and my good friend Juani on our 1st day
All of us… the participants

Juani, Nora and myself 🙂
The last day of the course. Receiving the certificate from Mr Iskandar, the Otologist from HKL
With the Profs, otologists and fellow participants on our last day.