Introduction: Cultural backgrounds can influence the smell test because of the unfamiliarity of d... more Introduction: Cultural backgrounds can influence the smell test because of the unfamiliarity of different populations with a number of odorants. The study aims to determine the cutoff points for hyposmia using the cultural adaptation of the Malaysian version of the Sniffin’ Sticks identification smell test among different age groups. Methods: In this cross-sectional study, healthy participants were recruited from a hospital, senior citizen homes, and schools from 2019 until 2021. Participants were divided into 5 different age groups (A: children, B: adolescents, C: young adults, D: middle-aged adults, and E: older adults) and underwent the identification smell test. Scores below the 10th percentile in these age groups were used to determine the cutoff points for hyposmia. Results: The cutoff points for the smell identification scores for hyposmia at the 10th percentile in children, adolescents, and adults (young, middle-aged, and older) were less than 6, 9, and 11, respectively. Pai...
carcinoma. We proceeded with bilateral We report a 60 year old man diagnosed to have modified nec... more carcinoma. We proceeded with bilateral We report a 60 year old man diagnosed to have modified neck dissection and patient bilateral tonsillar carcinoma. He presented underwent Radiation therapy. (Rawal Med J with bilateral neck swelling with suspicious 2013;38:79-80). looking tonsils. Bilateral wide excision Key words: Bilateral tonsillar carcinoma, bilateral tonsillectomy was done. Histopathology neck disease. showed localized bilateral squamous cell
Objective: To determine the pattern of cellular infiltration of Nasal Polyps (NP) in different Ma... more Objective: To determine the pattern of cellular infiltration of Nasal Polyps (NP) in different Malaysian ethnic groups who co-exist within the same environment. Methodology: A total of 176 patients with CRS with nasal polyposis (CRSwNP) were included in the study. Disease severity was measured by endoscopic examination and computed tomography (CT) using Lund-Mackay scoring system. The number of eosinophils and non-eosinophils were counted, and average number of inflammatory cells for each high power field was calculated. Results: Eosinophil-predominant CRSwNP was seen in 35.8% of patients and 64.2% had non-eosinophil-predominant CRSwNP. Non-eosinophil predominant subtypes could be divided into neutrophil (31.3%), plasma cells and others (33%). Phenotypes of CRSwNP showed a significant association with ethnicity (x² = 9.640; p 0.05). Conclusion: Our study showed Malaysian Chinese and Malay ethnic groups had a non-eosinophilic phenotype of nasal polyps. This was particularly the case ...
Distinguishing physiologic and pathologic genu varus is challenging among children below age 3. T... more Distinguishing physiologic and pathologic genu varus is challenging among children below age 3. They can be assessed by measuring intercondylar distance (ICD), clinical tibiofemoral angle (cTFA) or radiologic TFA (rTFA). We aim to determine the knee measurement values among three groups of children. Medline (1946-) and EMBase (1947-) were searched until 31 July 2020 using a search strategy. Studies with original data which reported knee measurements among children with normal alignment, physiologic and pathologic bowing between the ages of 0-3 years were included. In total 1897 studies were identified, and 16 studies included after title and abstract screening. These studies involved 1335 patients with normal alignment, 286 with physiologic and 184 with pathologic bowing. Five studies provided data on ICD, seven on cTFA and eight on rTFA which were pooled for meta-analyses. Normal children had neither measurable ICD nor demonstrable varus on cTFA after 19 months old. The mean (95% confidence interval) ICD for children with pathologic genu varus at 18 months was 4.41 (4.19-4.63). The rTFA for children with pathologic compared to the physiologic bowing by age groups was; 11-20 months: 24.74°(23.22°-26.26°) vs. 19.44°(17.05°-21.84°), 21-30 months: 20.35°(18.13°-22.56°) vs. 14.72°(12.32°-17.12°) and 12-36 months: 32.60°(26.40°-38.80°) vs. 19.14°(17.78°-20.50°). Children above the age of 18 months with genu varus should be closely monitored clinically using ICD or cTFA. An ICD of more than 4 cm may warrant further investigation for pathologic cause. rTFA has limited use in the detection of pathologic varus.
Nasal peak inspiratory flow (NPIF) is a practical and affordable tool that measures maximum inspi... more Nasal peak inspiratory flow (NPIF) is a practical and affordable tool that measures maximum inspiratory flow rate through both nostrils. Although NPIF values for healthy controls and patients appear to differ considerably, a generally expected value for populations with and without nasal obstruction has yet to be established. The aim of this systematic review and meta‐analysis was to determine the mean NPIF value in populations with and without nasal obstruction.
Indian Journal of Otolaryngology and Head & Neck Surgery
Pathologies of the branchial apparatus originate from abnormal embryological development and freq... more Pathologies of the branchial apparatus originate from abnormal embryological development and frequently affects the second branchial cleft. Fourth branchial cleft lesions are exceptionally few and existing literature on it is scarce. We present a case of a fourth branchial pouch sinus, masquerading as a recurrent neck abscess.
Background: Allergen specific immunoglobulin E (spIgE) in the nasal mucosa is a biomarker for loc... more Background: Allergen specific immunoglobulin E (spIgE) in the nasal mucosa is a biomarker for local allergic rhinitis. Inferior turbinate tissue biopsy is a sensitive method to detect nasal spIgE but is invasive. Nasal brushing is a relatively noninvasive method to detect nasal spIgE that may be of comparable diagnostic utility. Objective: To assess the performance of nasal brushing to obtain a nasal spIgE sample compared with an inferior turbinate tissue biopsy among patients who underwent turbinate surgery. Methods: A diagnostic cross-sectional study that involved participants who were undergoing turbinate surgery was performed. Nasal brushing, inferior turbinate tissue biopsy, blood collection, and skin-prick test (SPT) were performed perioperatively and tested for house-dust allergens. A receiver operating curve was used to assess the performance of the nasal brushings to obtain nasal spIgE samples compared with the inferior turbinate tissue biopsy. The diagnostic utility of nas...
Background Not all rhinitis patients are affected by an immunoglobulin E (IgE)-mediated inflammat... more Background Not all rhinitis patients are affected by an immunoglobulin E (IgE)-mediated inflammatory process. Skin and serum allergy assessments are limited in their ability to define local allergic rhinitis (LAR). Thus, patients with negative systemic allergy assessments comprise a mix of those who truly have nonallergic rhinitis (NAR) and patients with LAR. Objective To determine the clinical characteristics of patients with NAR. Methods A cross-sectional study was performed on consecutive adults with rhinitis symptoms who underwent turbinate surgery. NAR patients were defined by excluding allergy using both systemic (serum-specific IgE and/or skin prick test) and local (inferior turbinate tissue-specific IgE) tests. Allergic rhinitis (AR) patients were defined by any positive systemic or local test toward aeroallergens. The clinical characteristics studied included allergic comorbidities (asthma, eczema, allergic conjunctivitis), inhalant allergen triggers (dust, pollen, animal d...
Background Specific immunoglobulin E (sIgE) within the nasal airway is likely to be the most idea... more Background Specific immunoglobulin E (sIgE) within the nasal airway is likely to be the most ideal marker of allergic status, but little is known of the normative values in asymptomatic patients and those with rhinitis. Objective The aim of this study was to assess the diagnostic characteristics of inferior turbinate tissue biopsy sIgE in asymptomatic and rhinitic patients. Methods A diagnostic cross-sectional study was undertaken, involving patients who underwent inferior turbinate surgery with or without other surgical interventions. Inferior turbinate tissue biopsy was performed during surgery and was assessed for allergen sIgE (dust mite, grass [temperate or subtropical], and animal epithelium) using an automated immunoassay. Tissue sIgE was assessed among asymptomatic patients and those with nasal symptoms. Data were presented as median (interquartile range). A receiver operating curve was used to predict the diagnostic utility of turbinate tissue sIgE in determining allergic r...
Middle turbinate head edema has recently been found to have high specificity for diagnosis of inh... more Middle turbinate head edema has recently been found to have high specificity for diagnosis of inhalant allergy. However, subtle mucosal edema can be difficult to appreciate under white light endoscopy. Narrow band imaging (NBI) has the potential to demonstrate edema by identifying reduced mucosal vascularity and improve sensitivity for the detection of mucosal edema. Narrow band imaging was assessed to determine its utility in objectifying mucosal edema. A cross-sectional diagnostic study was performed on patients with edematous mucosa of the middle turbinate head. Under traditional white light endoscopy, areas of edematous mucosa were identified. Using NBI, these areas were compared to areas of normal mucosa on the middle turbinate head. NBI images of these same areas were then converted to grey scale and a vascularity index was created by pixel analysis and brightness in Fiji Image J software (Wisconsin, US). Thirty-three middle turbinates were assessed (age 42.4 ± 12.5, 42.4% fem...
Allergen specific immunoglobulin can be present in the nasal mucosa of patients with non-allergic... more Allergen specific immunoglobulin can be present in the nasal mucosa of patients with non-allergic rhinitis (NAR). This condition is defined as local allergic rhinitis. However, the reported presence of nasal specific immunoglobulin E (nspIgE) among NAR is variable. The aim of this review was to summarize the studies which reported the presence of nspIgE among patients diagnosed as NAR. Embase (1947- ) and Medline (1946-) were searched until 6th June 2017. A search strategy was utilized to identify studies on nspIgE among patients with NAR. The target population was patients with symptoms of rhinitis, but negative systemic allergen sensitization. Studies with original data on detectable nspIgE among the NAR population were included. Meta-analysis of single proportions as a weighted probability %(95%CI) was performed. Heterogeneity was explored amongst studies. A search strategy returned 2286 studies and 21 were included. These studies involved 648 participants with NAR. NspIgE was de...
Journal of neurological surgery. Part B, Skull base, 2018
Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa ... more Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa pathology is essential for the skull base surgeon. The vidian nerve and eustachian tube (ET) cartilage come together at the foramen lacerum, the vidian-eustachian junction (VEJ). The ICA position, relative to the VEJ is described. Endoscopic dissection of adult fresh-frozen cadaver ICAs and a case series of patients with petroclival pathology were performed. The relationship of the VEJ to the ICA horizontal segment, vertical segment, and second genu was assessed. The distance of the ICA second genu to VEJ was determined in coronal, axial, and sagittal planes. The length of the vidian nerve and ET was measured from the pterygopalatine fossa (PPF) and nasopharyngeal orifice to the VEJ. In this study, 10 cadaver dissections (82.3 ± 6.7 years, 40% female) were performed. The horizontal petrous ICA was at or behind VEJ in 100%, above VEJ in 100%, and lateral to VEJ in 80%. The vertical para...
Introduction: Cultural backgrounds can influence the smell test because of the unfamiliarity of d... more Introduction: Cultural backgrounds can influence the smell test because of the unfamiliarity of different populations with a number of odorants. The study aims to determine the cutoff points for hyposmia using the cultural adaptation of the Malaysian version of the Sniffin’ Sticks identification smell test among different age groups. Methods: In this cross-sectional study, healthy participants were recruited from a hospital, senior citizen homes, and schools from 2019 until 2021. Participants were divided into 5 different age groups (A: children, B: adolescents, C: young adults, D: middle-aged adults, and E: older adults) and underwent the identification smell test. Scores below the 10th percentile in these age groups were used to determine the cutoff points for hyposmia. Results: The cutoff points for the smell identification scores for hyposmia at the 10th percentile in children, adolescents, and adults (young, middle-aged, and older) were less than 6, 9, and 11, respectively. Pai...
carcinoma. We proceeded with bilateral We report a 60 year old man diagnosed to have modified nec... more carcinoma. We proceeded with bilateral We report a 60 year old man diagnosed to have modified neck dissection and patient bilateral tonsillar carcinoma. He presented underwent Radiation therapy. (Rawal Med J with bilateral neck swelling with suspicious 2013;38:79-80). looking tonsils. Bilateral wide excision Key words: Bilateral tonsillar carcinoma, bilateral tonsillectomy was done. Histopathology neck disease. showed localized bilateral squamous cell
Objective: To determine the pattern of cellular infiltration of Nasal Polyps (NP) in different Ma... more Objective: To determine the pattern of cellular infiltration of Nasal Polyps (NP) in different Malaysian ethnic groups who co-exist within the same environment. Methodology: A total of 176 patients with CRS with nasal polyposis (CRSwNP) were included in the study. Disease severity was measured by endoscopic examination and computed tomography (CT) using Lund-Mackay scoring system. The number of eosinophils and non-eosinophils were counted, and average number of inflammatory cells for each high power field was calculated. Results: Eosinophil-predominant CRSwNP was seen in 35.8% of patients and 64.2% had non-eosinophil-predominant CRSwNP. Non-eosinophil predominant subtypes could be divided into neutrophil (31.3%), plasma cells and others (33%). Phenotypes of CRSwNP showed a significant association with ethnicity (x² = 9.640; p 0.05). Conclusion: Our study showed Malaysian Chinese and Malay ethnic groups had a non-eosinophilic phenotype of nasal polyps. This was particularly the case ...
Distinguishing physiologic and pathologic genu varus is challenging among children below age 3. T... more Distinguishing physiologic and pathologic genu varus is challenging among children below age 3. They can be assessed by measuring intercondylar distance (ICD), clinical tibiofemoral angle (cTFA) or radiologic TFA (rTFA). We aim to determine the knee measurement values among three groups of children. Medline (1946-) and EMBase (1947-) were searched until 31 July 2020 using a search strategy. Studies with original data which reported knee measurements among children with normal alignment, physiologic and pathologic bowing between the ages of 0-3 years were included. In total 1897 studies were identified, and 16 studies included after title and abstract screening. These studies involved 1335 patients with normal alignment, 286 with physiologic and 184 with pathologic bowing. Five studies provided data on ICD, seven on cTFA and eight on rTFA which were pooled for meta-analyses. Normal children had neither measurable ICD nor demonstrable varus on cTFA after 19 months old. The mean (95% confidence interval) ICD for children with pathologic genu varus at 18 months was 4.41 (4.19-4.63). The rTFA for children with pathologic compared to the physiologic bowing by age groups was; 11-20 months: 24.74°(23.22°-26.26°) vs. 19.44°(17.05°-21.84°), 21-30 months: 20.35°(18.13°-22.56°) vs. 14.72°(12.32°-17.12°) and 12-36 months: 32.60°(26.40°-38.80°) vs. 19.14°(17.78°-20.50°). Children above the age of 18 months with genu varus should be closely monitored clinically using ICD or cTFA. An ICD of more than 4 cm may warrant further investigation for pathologic cause. rTFA has limited use in the detection of pathologic varus.
Nasal peak inspiratory flow (NPIF) is a practical and affordable tool that measures maximum inspi... more Nasal peak inspiratory flow (NPIF) is a practical and affordable tool that measures maximum inspiratory flow rate through both nostrils. Although NPIF values for healthy controls and patients appear to differ considerably, a generally expected value for populations with and without nasal obstruction has yet to be established. The aim of this systematic review and meta‐analysis was to determine the mean NPIF value in populations with and without nasal obstruction.
Indian Journal of Otolaryngology and Head & Neck Surgery
Pathologies of the branchial apparatus originate from abnormal embryological development and freq... more Pathologies of the branchial apparatus originate from abnormal embryological development and frequently affects the second branchial cleft. Fourth branchial cleft lesions are exceptionally few and existing literature on it is scarce. We present a case of a fourth branchial pouch sinus, masquerading as a recurrent neck abscess.
Background: Allergen specific immunoglobulin E (spIgE) in the nasal mucosa is a biomarker for loc... more Background: Allergen specific immunoglobulin E (spIgE) in the nasal mucosa is a biomarker for local allergic rhinitis. Inferior turbinate tissue biopsy is a sensitive method to detect nasal spIgE but is invasive. Nasal brushing is a relatively noninvasive method to detect nasal spIgE that may be of comparable diagnostic utility. Objective: To assess the performance of nasal brushing to obtain a nasal spIgE sample compared with an inferior turbinate tissue biopsy among patients who underwent turbinate surgery. Methods: A diagnostic cross-sectional study that involved participants who were undergoing turbinate surgery was performed. Nasal brushing, inferior turbinate tissue biopsy, blood collection, and skin-prick test (SPT) were performed perioperatively and tested for house-dust allergens. A receiver operating curve was used to assess the performance of the nasal brushings to obtain nasal spIgE samples compared with the inferior turbinate tissue biopsy. The diagnostic utility of nas...
Background Not all rhinitis patients are affected by an immunoglobulin E (IgE)-mediated inflammat... more Background Not all rhinitis patients are affected by an immunoglobulin E (IgE)-mediated inflammatory process. Skin and serum allergy assessments are limited in their ability to define local allergic rhinitis (LAR). Thus, patients with negative systemic allergy assessments comprise a mix of those who truly have nonallergic rhinitis (NAR) and patients with LAR. Objective To determine the clinical characteristics of patients with NAR. Methods A cross-sectional study was performed on consecutive adults with rhinitis symptoms who underwent turbinate surgery. NAR patients were defined by excluding allergy using both systemic (serum-specific IgE and/or skin prick test) and local (inferior turbinate tissue-specific IgE) tests. Allergic rhinitis (AR) patients were defined by any positive systemic or local test toward aeroallergens. The clinical characteristics studied included allergic comorbidities (asthma, eczema, allergic conjunctivitis), inhalant allergen triggers (dust, pollen, animal d...
Background Specific immunoglobulin E (sIgE) within the nasal airway is likely to be the most idea... more Background Specific immunoglobulin E (sIgE) within the nasal airway is likely to be the most ideal marker of allergic status, but little is known of the normative values in asymptomatic patients and those with rhinitis. Objective The aim of this study was to assess the diagnostic characteristics of inferior turbinate tissue biopsy sIgE in asymptomatic and rhinitic patients. Methods A diagnostic cross-sectional study was undertaken, involving patients who underwent inferior turbinate surgery with or without other surgical interventions. Inferior turbinate tissue biopsy was performed during surgery and was assessed for allergen sIgE (dust mite, grass [temperate or subtropical], and animal epithelium) using an automated immunoassay. Tissue sIgE was assessed among asymptomatic patients and those with nasal symptoms. Data were presented as median (interquartile range). A receiver operating curve was used to predict the diagnostic utility of turbinate tissue sIgE in determining allergic r...
Middle turbinate head edema has recently been found to have high specificity for diagnosis of inh... more Middle turbinate head edema has recently been found to have high specificity for diagnosis of inhalant allergy. However, subtle mucosal edema can be difficult to appreciate under white light endoscopy. Narrow band imaging (NBI) has the potential to demonstrate edema by identifying reduced mucosal vascularity and improve sensitivity for the detection of mucosal edema. Narrow band imaging was assessed to determine its utility in objectifying mucosal edema. A cross-sectional diagnostic study was performed on patients with edematous mucosa of the middle turbinate head. Under traditional white light endoscopy, areas of edematous mucosa were identified. Using NBI, these areas were compared to areas of normal mucosa on the middle turbinate head. NBI images of these same areas were then converted to grey scale and a vascularity index was created by pixel analysis and brightness in Fiji Image J software (Wisconsin, US). Thirty-three middle turbinates were assessed (age 42.4 ± 12.5, 42.4% fem...
Allergen specific immunoglobulin can be present in the nasal mucosa of patients with non-allergic... more Allergen specific immunoglobulin can be present in the nasal mucosa of patients with non-allergic rhinitis (NAR). This condition is defined as local allergic rhinitis. However, the reported presence of nasal specific immunoglobulin E (nspIgE) among NAR is variable. The aim of this review was to summarize the studies which reported the presence of nspIgE among patients diagnosed as NAR. Embase (1947- ) and Medline (1946-) were searched until 6th June 2017. A search strategy was utilized to identify studies on nspIgE among patients with NAR. The target population was patients with symptoms of rhinitis, but negative systemic allergen sensitization. Studies with original data on detectable nspIgE among the NAR population were included. Meta-analysis of single proportions as a weighted probability %(95%CI) was performed. Heterogeneity was explored amongst studies. A search strategy returned 2286 studies and 21 were included. These studies involved 648 participants with NAR. NspIgE was de...
Journal of neurological surgery. Part B, Skull base, 2018
Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa ... more Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa pathology is essential for the skull base surgeon. The vidian nerve and eustachian tube (ET) cartilage come together at the foramen lacerum, the vidian-eustachian junction (VEJ). The ICA position, relative to the VEJ is described. Endoscopic dissection of adult fresh-frozen cadaver ICAs and a case series of patients with petroclival pathology were performed. The relationship of the VEJ to the ICA horizontal segment, vertical segment, and second genu was assessed. The distance of the ICA second genu to VEJ was determined in coronal, axial, and sagittal planes. The length of the vidian nerve and ET was measured from the pterygopalatine fossa (PPF) and nasopharyngeal orifice to the VEJ. In this study, 10 cadaver dissections (82.3 ± 6.7 years, 40% female) were performed. The horizontal petrous ICA was at or behind VEJ in 100%, above VEJ in 100%, and lateral to VEJ in 80%. The vertical para...
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