Virtual Reality Surgical Training in Ear, Nose and Throat Surgery


Virtual reality has been introduced to the medical field and it is now used in medical education as an alternative high fidelity simulator. The major components to successful learning that has contributed to the efficacy of the virtual reality system are the ability to provide repetitive practice under controlled environment, self-directed learning and proved construct validity. This review evaluated the validity and the efficacy of current virtual reality systems in ear, nose and throat surgery.

Invasive Fungal Rhinosinusitis versus Bacterial Rhinosinusitis with Orbital Complications: A Case-Control Study.


Background. Invasive fungal rhinosinusitis with orbital complications (IFSwOC) is a life-threatening condition. The incidence of mortality has been reported to be up to 80 percent. This study was conducted to determine the risk factors, presentations, clinical, and imaging findings that could help to manage this condition promptly. Methods. We conducted a case-control study of 100 patients suffering from rhinosinusitis with orbital complications. The risk factors, clinical presentations, radiological findings, medical and surgical managements, durations of hospital stay, and mortality rate data were collected. Results. Sixty-five patients were diagnosed with IFSwOC, while the other thirty-five patients composed the control group. The most important risk factor for IFSwOC was diabetes mellitus. Visual loss and diplopia were the significant symptom predictors. The significant clinical predictors were nasal crust, oculomotor nerve, and optic nerve involvement. The CT findings of IFSwOC were sinus wall erosion and hyperdensity lesions. The mortality rate was 25.71 percent in the IFSwOC group and 3.17 percent in the control group. Conclusions. Invasive fungal rhinosinusitis with orbital complications is symptomatic of a high mortality rate. The awareness of a patient’s risk factors, the presenting symptoms, signs of fungal invasion, and aggressive management will determine the success of any treatment procedures.

Chronic rhinosinusitis and emerging treatment options

This review describes the epidemiology and various treatments in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Evidence for short-term use of systemic corticosteroids has been shown to be favorable in CRSwNP, but still limited in CRSsNP. Topical corticosteroids improve symptom scores in both CRS subgroups. The role of microbes in CRS is still controversial. Culture-directed antibiotics are recommended for CRSsNP with exacerbation. Long-term use of low dosage antibiotics is recommended for CRSsNP for their anti-inflammatory effects. Other emerging treatment options are also discussed.

Acute Versus Chronic Invasive Fungal Rhinosinusitis: A Case-Control Study

Authors: Patorn Piromchai and Sanguansak Thanaviratananich

Introduction: Invasive fungal rhinosinusitis is a challenging condition that can be found mostly in immunocompromised patients. Failure to diagnose and treat this entity promptly usually results in rapid progression and death. The purpose of this study was to determine clinical presentation, complication and morbidity in patients with acute versus chronic invasive fungal rhinosinusitis.

Setting and design: Case-control study at Srinagarind Hospital, Khon Kaen University between January 1998 and May 2008.

Methods: The patient’s data with the diagnosis of invasive fungal rhinosinusitis was included. Demographic data, underlying diseases, presenting symptoms, histologic sinonasal tissue evaluations, sinonasal tissue cultures, CT scan findings, surgical interventions, morbidity, and mortality were collected.

Results: Sixty-five patients were diagnosed as invasive fungal rhinosinusitis between January 1998 and May 2008. The data of six patients were unable to obtain. Fifty-nine patients were included in this study. Patients with immunocompromised status have significant greater risk for acute than chronic IFS, OR = 6.5 (P = 0.004). Patients with mucosal necrosis have the significant higher risk for acute IFS, OR = 5.5 (P = 0.01). There was no significant difference in orbital complications proportion between acute and chronic invasive fungal rhinosinusitis, OR = 2.42 (P = 0.15). Sinus wall erosion have found significantly in chronic IFS group, OR = 0.24 (P = 0.02). The average hospital stayed was 30.58 ± 26.43 days with no difference between groups (P = 0.50). Fourteen patients in acute IFS group were dead (31.11%) while all patients in chronic IFS group were survived.

Conclusions: Invasive fungal rhinosinusitis continues to present a challenge to the otolaryngologist. Acute IFS was found most commonly in immunocompromised patients. The most consistent finding of acute IFS was mucosal necrosis and black crust/debris. The CT finding of sinus wall erosion may help in diagnosis of chronic IFS.

Diagnosis and Treatment of Anaplastic Thyroid Carcinoma

Patorn Piromchai, Teeraporn Ratanaanekchai, Pornthep Kasemsiri
Anaplastic Thyroid Carcinoma; Thyroid; Cancer
Anaplastic thyroid carcinoma (ATC) is a poorly differentiated thyroid cancer. It cannot uptake iodine or synthesis thyroglobulin. The incidence is low; about 2% – 5% of thyroid cancer. The peak age incidence is 60 – 70 years and it is more common in females (55% – 77% of all patients). In recent years, the incidence has declined; however, it may be higher in areas of endemic goiter. ATC may occur with a coexisting carcinoma and may represent transformation of a well-differentiated thyroid cancer. Patients typically present with a rapidly growing anterior neck mass and aggressive symptoms. The most reliable tool in detecting thyroid malignancies is fine-needle aspiration cytology (FNAC). Sensitivity of FNAC for thyroid malignancy ranged from 61% to 97.7%. Fine-needle aspiration can diagnose ATC by the demonstration of spindled or giant cells, bizarre neoplastic cells that may be multinucleated, or atypical cells with high mitotic activity. A syncytial pattern is the predominant cellular pattern of anaplastic thyroid carcinoma. Other laboratory tests, including tumor markers (cytokeratin, vimentin, and carcinoembryogenic antigen) are helpful in diagnosis and follow-up of the patients. Multimodality therapy (surgery, external beam radiation, and chemotherapy) is the recommended treatment and it seems to have slightly improved outcomes. The prognosis is not as bad in younger patients with smaller tumors. The most common cause of death is lung metastasis. The mean survival time is less than 6 months from the time of diagnosis. The prompt diagnosis and aggressive treatment are essential modality to achieve optimal outcomes.

A Child Presenting with a Bullet in the Middle Ear: Case Report

Authors: Patorn Piromchai, Somchai Srirompotong, Piyawadee Lertchanaruengrith and Robert Mills


Introduction: Foreign bodies in the external auditory canal are common in both adults and children. Removal of the foreign body requires skill, but is usually successfully performed in the emergency department. We report a case of a child with a bullet in ear canal which was pushed into the middle ear during an attempt to remove it.


Case Presentation: A 6-year-old Thai boy went to the community hospital with his parents, who reported that their child had pushed a bullet into his ear. Otoscopic examination revealed a metallic foreign body in his external auditory canal. The first attempt to remove the foreign body failed and the child was referred to an otolaryngologist. We found that the tympanic membrane was ruptured, with granulation tissue in the middle ear and the bullet was located in the hypotympanum. The foreign body was removed via a post-auricular approach.


Conclusion: Removal of a foreign body from external auditory canal is an essential skill for physicians. Careful removal can prevent further trauma and complications. When the first attempt fails, referral to an otolaryngologist is recommended.

Psychological Status in Patients Seeking Rhinoplasty

Authors: Patorn Piromchai, Surapol Suetrong and Suwanna Arunpongpaisal


Background: Rhinoplasty is the most common operation performed by our facial plastic surgery unit. Recognition of patients with psychological problems which may result in an unfavourable post-operative outcome is essential. The objective of this study was to evaluate the psychological status of patients seeking rhinoplasty, compared with the general population.

Methods: We prospectively collected the data from patients who requested rhinoplasty in Srinagarind hospital, Thailand and controls. We used the general health questionnaire-28 (GHQ-28) for psychological problems detection.

Results: We included a total of 196 participants, 98 in study group and 98 in control group. The study group has a 5.5 times (95% CI 1.25 to 24.17, P = 0.01) higher risk for poor mental status more than control group.

Conclusions: The patients seeking rhinoplasty group were more likely to have psychological problems when compared with the control group. Surgeons should be aware of the patient’s psychological status before performing the operation.

Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults.

Piromchai P, Thanaviratananich S, Laopaiboon M.

Department of Otorhinolaryngology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, 40002.



Chronic rhinosinusitis (CRS) is a common health problem which significantly affects quality of life. A wide range of medical and surgical therapies have been used to treat CRS. Both systemic and topical antibiotics are used with the aim of eliminating infection and inflammation, altering bacterial biofilm formation, reversing ostial occlusion and improving symptoms. Various groups of systemic antibiotics have been studied; clinical cure rates reported are inconsistent and range from 50% to 95%.


To determine the effectiveness and adverse reactions associated with systemic antibiotic therapy for CRS in adults.


We searched the Cochrane ENT Group Trials Register; CENTRAL (2010, Issue 2); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 10 June 2010.


Randomised controlled trials (RCTs) comparing systemic antibiotics with placebo for chronic rhinosinusitis in adults.


Two authors extracted data independently, compared results and resolved disagreements by discussion. We assessed treatment effect by calculating the risk ratio (RR) and 95% confidence intervals (CI) of cure at a specific time point for each trial. We used mean difference (MD) and 95% CI for continuous variables (severity scores, duration of symptoms, etc.).


We included one study involving 64 patients. We assessed the overall risk of bias in this study as high. The study reported that roxithromycin could reduce the mean response score of patients by 0.73 points on a 1 to 6-point scale (95% CI 0.32 to 1.14, P = 0.0005) compared to those on placebo at three months after the start of treatment. This study also used sinonasal outcome test-20 (SNOT-20) comparing between pre and post-treatment at six, 12 and 24 weeks. The mean change in SNOT-20 from baseline at 24 weeks in the roxithromycin group was not significantly more than in the placebo group, at 0.27 points (95% CI -0.24 to 0.78, P = 0.30) on a 0 to 5-point scale.


There is limited evidence from one small study to support the use of systemic antibiotics for the curative treatment of chronic rhinosinusitis in adults. Further good quality trials, with large sample sizes, are needed to evaluate the use of antibiotics in chronic rhinosinusitis.

Alternative Agents to Prevent Fogging in Head and Neck Endoscopy


Background: The essential factor for diagnosis and treatment of diseases in head and neck endoscopy is the visibility of the image. An anti-fogging agent can reduce this problem by minimizing surface tension to prevent the condensation of water in the form of small droplets on a surface. There is no report on the use of hibiscrub? or baby shampoo to reduce fogging in the literature. The objective of this study was to compare the efficacy between commercial anti-fogging agent, hibiscrub? and baby shampoo to reduce fogging for the use in head and neck endoscopy. Methods: The study was conducted at the Department of Otorhinolaryngology, Faculty of Medicine, Khon Kaen University in August 2010. Commercial anti-fogging agent, baby shampoo and hibiscrub? were applied on rigid endoscope lens before putting them into a mist generator. The images were taken at baseline, 15 seconds, 30 seconds and 1 minute. The images? identifiers were removed before they were sent to two evaluators. A visual analogue scale (VAS) was used to rate the image quality from 0 to 10. Results: The difference in mean VAS score between anti-fogging agent, baby shampoo and hibiscrub? versus no agent were 5.46, 4.45 and 2.1 respectively. The commercial anti-fogging agent and baby shampoo had most protective benefit and performed significantly better than no agent (P < 0.05). Conclusions: Baby shampoo is an effective agent to prevent fogging during head and neck endoscopy and compares favourably with commercial anti-fogging agent.

Fractured metallic tracheostomy tube in a child: a case report and review of the literature

Piromchai P,?Lertchanaruengrit P,?Vatanasapt P,?Ratanaanekchai T,?Thanaviratananich S.


INTRODUCTION:?Tracheostomy is a common airway procedure for life support. The fracture of the tracheostomy tube is a rare complication. We report a case of a 14-year-old boy whose fractured stainless steel tracheostomy tube dislodged into the tracheobronchial tree. We include a literature review and proposed recommendations for tracheostomy care.

CASE PRESENTATION:?A 14-year-old Thai boy who had a stainless steel tracheostomy tube presented with a complaint of intermittent cough for 2 months. During tracheostomy tube cleaning, his parents found that the inner tube was missing. A chest X-ray revealed a metallic density foreign body in his right main bronchus. He underwent bronchoscopic removal of the inner tracheostomy tube and was discharged without further complications.

CONCLUSION:?A fractured tracheostomy tube is a rare complication. Appropriate cleaning and scheduled replacement of the tracheostomy tube may prevent this complication