Chronic oral ulcer in patients with rheumatoid arthritis is a diagnostic challenge in primary health care. The possible causes include the disease itself, side effect of treatment, malignancy and infections. This is a case of a 63-year-old woman with underlying rheumatoid arthritis presented with chronic solitary oral ulcer. She was on oral methotrexate (MTX) and high dose folic acid for five years with good compliance. Tissue biopsy showed marked inflammatory cells infiltration and nuclear hyperchromatism with no evidence of malignancy nor infection. The ulcer was resolved after completing antifungal treatment for six weeks following failure of improvement after empirical antibiotic, elimination of possible trauma and discontinuation of MTX. The fungal staining was negative. There are possibilities of false negative results, thus broadened diagnosis with repeated and further investigations are recommended in cases who did not respond to conventional treatment.

Introduction: An aberrant carotid artery has distinct terms and may exhibit a submucosal mass in the posterior pharyngeal wall. While it is primarily asymptomatic, an extreme aberrancy doubles the risk of dissection, a cerebrovascular accident (CVA) and an injury intraoperatively. Case Report: We report a case of ‘kissing carotid artery’ in a 65-year-old lady who presented with a foreign body sensation felt in the throat for one week. A finding of flexible nasopharyngolaryngoscopy (FNPLS) showed a bilateral paramedian retropharyngeal pulsating mass. Radiological examinations, including Computed Tomography (CT) of the neck and an angiogram, revealed an aberrant course of bilateral carotid arteries. In view of no malignancy and vascular malformations, there was no further intervention done, and the patient was subjected to yearly surveillance. Conclusion: Retropharyngeal carotid arteries are clinically significant anatomic variants. Such anomalies are potentially life-threatening and a risk factor for a severe hemorrhage during the simplest and commonly performed transoral surgeries. Thus, thorough perioperative assessment with accurate imaging techniques and studies are required to evaluate these anomalies and may avoid any disastrous complications.

Congenital defect to the foramen of Huschke with a manifestation as temporomandibular joint (TMJ) soft tissue herniation in a radiological study is rare. The patient may present with nonspecific symptoms such as otalgia, mandibular joint pain, tinnitus and conductive hearing loss, and scarcely cervicofacial subcutaneous emphysema. Here, we report a patient presented with cervicofacial subcutaneous emphysema secondary to a congenital defect of the foramen of Huschke. A 45-year-old gentleman presented with right-sided neck swelling and right otalgia with a crackling sound over the right ear upon chewing. Examination shows right-sided fullness with subcutaneous emphysema from the zygoma to the upper neck. Otherwise, it is non-tender with no skin changes, and the facial nerve is intact. Otoendoscopy shows erythematous soft tissue bulging of the anterior wall of the right external auditory canal (EAC) upon closing the mouth and prolapsing upon mouth opening. The right tympanic membrane was intact. Contrast-enhanced computer tomography (CECT) of the neck and temporal region revealed extensive cervicofacial subcutaneous emphysema with a bony defect at the anterior wall of the right EAC, indicating fistulous communication between the right EAC and TMJ. The subcutaneous emphysema resolved on the treatment of the right otitis externa. The patient is subjected to a combined approach of open and endoscopic-assisted repair of the anterior EAC wall defect. TMJ herniation into the anterior EAC is rare; however, the patient presentation may vary. CECT is the gold standard for diagnosing and facilitating treatment options. Treatment choice is based on the patient's condition, including conservative or surgical intervention.

Retropharyngeal abscess is life-threatening with potential airway emergency. A 53-year-old lady with diabetes mellitus presented with diffuse painful neck swelling for a week and difficulty in breathing with stridor. Video laryngoscopy done in operating theatre showed edematous laryngeal inlets with bulging posterior pharyngeal wall. Patient was tested positive for COVID-19 infection. The management was taken with high precautions, careful planning with unconventional and multidisciplinary approach. Management included airway protection, antibiotic, surgical drainage and correction of hyperglycaemia besides the compliance to COVID-19 SOP. Prognosis is good if identified early, managed aggressively and complications are avoided albeit the comorbidity and COVID-19 infective status

The Coronavirus disease 2019 (COVID-19) pandemic is a devastating global pandemic affecting many countries worldwide. It has a huge impact on the country’s healthcare system as well as its socio-economic wellbeing. Majority of elective surgery was deferred in order to provide beds, resources and treat COVID-19 cases. Resumption of elective surgery requires a well-planned process and adherence to standard guidelines to protect both the healthcare providers and patients. Pre-operative COVID-19 screening will be one of the new norms for patients undergoing surgery. This study was aimed to evaluate the pre-operative COVID-19 screening for elective surgery among Otorhinolaryngology (ORL) patients in Hospital Ampang based on the current Malaysian guidelines for undertaking surgery during COVID-19 pandemic and highlight the screening protocols implemented by the Ministry of Health. This retrospective review was conducted in ORL Department, Hospital Ampang. We reviewed the surgical registry of 117 patients who underwent elective surgeries under general anaesthesia from June till September 2020. There were 62 patients (53%) below 18 years old and 55 patients (47%) above 18 years old. There were 76 cases (65%) involving aerosol-generating procedures. A total of 23 patients (19.7%) had COVID-19 screening done pre-operatively based on the Malaysian guidelines patient selection and all results were negative. None of the patients experienced any symptoms, complications or morbidities related to SARS-CoV-2 infection post-operatively. The Malaysian guideline on pre-operative screening for COVID-19 is applicable for institutions with low to moderate local transmission of SARS-CoV-2. Targeted group or risk-based protocols are beneficial for improving cost-effectiveness and reducing workload burden during the critical period. As the pandemic evolved, the guidelines have to be revised based on the prevailing situation to suit the best clinical practice for the benefit of patients and healthcare personnel without disrupting the surgical services.

Rhinolith is a calcareous concretion resulting from mineralization and encrustation of an endogenous or exogenous nidus in the nose. This rare clinical entity could be the result of a previous introduction of a foreign body into the nasal cavity. Rhinolith is rarely seen by the clinical practitioner. We report a case of rhinolith in a young healthy lady who presented with epistaxis and highlight the clinical presentation and management of this case. The history of foreign body insertion may be overlooked in such cases. Presence of grittiness on endoscopic probing aid in establishing the diagnosis. Early referral from primary care centre to ENT can avoid misdiagnosis and further complications as removal of the rhinolith is the ultimate treatment.

Branchial cleft cysts generally occur unilaterally at the lateral aspect of the neck. Bilateral branchial cysts are rare and may have familial associations. We report a rare case of non-syndromic bilateral branchial cyst in a 23-year-old woman who presented with chronic bilateral, progressively enlarging painless neck swellings. Complete surgical excision of the bilateral cyst was done. A histopathological examination confirmed the diagnosis. Precise diagnosis with early and complete surgical excision of branchial cysts may help prevent recurrence and other complications.

Pyogenic granuloma (PG) is a rapidly growing benign lesion of the skin and mucous membrane. Its etiology is still unclear. It is suggested to have arisen either due to trauma or hormonal influences. Pyogenic granuloma is regularly found in the oral cavity. Even though it is rare, it does occur in the nasal cavity and a few cases of pyogenic granuloma have been reported among the paediatric population. We present a case of a 6-year-old boy, who presented with unilateral nasal blockage and recurrent epistaxis. The child has a history of allergic rhinitis and frequent nasal picking. Clinical examination revealed a small broad based reddish mass at the anterior part of the right inferior turbinate. The histopathological examination from complete excisional biopsy was consistent with pyogenic granuloma. Although pyogenic granuloma is relatively rare, we should raise suspicion in young patients who complain of progressive unilateral nasal blockage and recurrent epistaxis, with or without a history of trauma. Thorough clinical examination is adequate in small lesion thus sparing the need for radiological investigation for bigger and extensive lesions. Complete excision is the ultimate treatment to avoid recurrence.

The rapid spread of the COVID-19 pandemic has led to a major public health crisis. Accurate screening methods for COVID-19 infection is essential and crucial for case detection, isolation, prevention and control of the current pandemic. At present, nasopharyngeal and oropharyngeal swabs are typically used as the method of choice for the diagnosis of SARS-CoV-2 infection. We carried out a review on the accuracy of the two different sampling sites, the nasopharyngeal and oropharyngeal swab sampling, focusing on the viral load, detection of positive cases and sensitivity in real-time polymerase chain reaction (RT-PCR) assay in diagnosing COVID-19. A total of 25 articles related to the topic were selected out of 5221 articles searched online using Scopus, PubMed and Medline, Embase, Web of Science, and Google scholar with the keywords COVID-19, SARS-CoV-2, nasopharyngeal swab, oropharyngeal swab, nasal swab and throat swab. All full text original articles were obtained and reviewed. Nasopharyngeal swab had significantly higher SARS-CoV-2 load than oropharyngeal swab (mean Ct value ranging from 24.3-37.8, higher detection of positive rate (highest rate 62.5%) and sensitivity (highest sensitivity 98.3%, P<0.05) in RT-PCR assay compared to oropharyngeal swab. Based on the scientific literature review, both nasopharyngeal and oropharyngeal swabs were reported to have 30% probability of yielding false negative results; thus clinically suspicious patients with negative results should be viewed with concern. In conclusion, although several methods of COVID-19 screening and type of specimen are available, nasopharyngeal swab is the best option for large scale screening as it yields significantly higher viral load, higher detection of positive rate among cases and higher sensitivity in RT-PCR assay compared to oropharyngeal swab in detecting SARS-CoV-2.

Nasopharyngeal carcinoma (NPC) is a rare malignancy worldwide. It is the fifth most common cancer among the Malaysian male. NPC is complex and unique in terms of its initial presentation. The patient usually presents late when the NPC is already in its advanced stage due to unusual and confusing nature of its manifestation which often misleads the clinician. Initial presentation of vision loss or impairment is rare in NPC. Up to date, there are only 9 reports of NPC cases presenting initially with impaired vision. We report a case of NPC with an uncommon initial presentation of bilateral visual impairment.