The Role of ENT Surgeons in Dermatomyositis - The Hong Kong ...

Message from the Presidentexemplified by his award winning schools andinstitution buildings. It was most fascinating andan eye opener, especially for us doctors. ProfessorFerlito from Italy, who received our CorrespondingFellowship in the afternoon, discussed with us theunusual neo-endocrine tumours of the larynx withmany beautiful pathological slides and pictures.Two months ago, we held our 12th DiplomaConferment Ceremony at the Academy andadmitted 4 new Fellows to our College. I thank allthe Fellows, Members and friends who took the timeto support this important event. For those who didnot have the time to attend, our First College Orationwas delivered by Dr. David Fang who spoke aboutthe role of the Medical Council, its Past, Present andFuture. With his usual articulate eloquence Dr. Fangtook us through the various missions and duties ofthe Council, its governance, the problems it facesand its future direction. All in all, a very informativeand interesting lecture of direct concern to us all. Dr.Herman Tang, President of the Hong Kong Societyof Otorhinolaryngology-Head & Neck Surgery,had kindly presented the Certificates of Merit andGeorge Choa prize to the winners of the SocietyTrainee’s Presentation competition. I had the honorof presenting the Society Prize to its winner. Manycongratulations to them!The College website is finally completed, thanksto the hard work of Dr. Li Ming Fai. Fellows cannow log on to the web for information. We welcomesuggestions and input on our website from Fellows.A number of scientific meetings will be forthcomingwith our conjoint sponsorship at the CUHK in theautumn months. Our College is also planning to cohosta meeting with the newly formed Hong KongVoice Foundation later this year. Details will beannounced in due course.Summer is getting near and many of us will beplanning our summer vacation. I wish you all ahappy and fruitful summer season.Kai Bun FUNGDuring the afternoon scientific session, Professorthe Hon. Patrick Lau showed us many beautifulpictures and graphics as he discussed with us themany aspects of architectural design in relationto our health, our well being and our living, well

Message from the EditorI would like to welcome more of our Fellows tothe Editorial Board. They are all bright stars ofour community and great writers. They will be ouracademic reviewers and will mastermind our newsection titled “The Journal Club” bringing all ourFellows the most relevant and up to date informationin our specialty. Dr Gerald Kam from PYNEH, DrBirgitta Wong from QMH, Dr Dennis Lee and DrFrederick Wong from PWH have done great in themaking of the new, yet important section of Senses.You might have noticed the Egytian tone to thepresent issue of Senses from the archeologicallypronounced Egytian ‘Tracheostomy’ at 3600BC asour cover to a heart warming cruise down the Nileby Dr Wendy Kwan in ‘A Lesiurely Note’ just to fosterthe correct mood in all for ‘Summer 2007’. If Egyptseems too far despite the beautiful sceneries ordinner at the Old Cataract, an armchair tour roundthe Hong Kong Sanatorium and Hospital by Dr TalenWai from TMH ( for those who haven’t been) mightbe interesting reading for a coffee break. We mustthank Dr Walton Li. Dr Patrick Wong and most ofall, Dr William Yip for facilitating the tour. I wish allour Fellows and Members a wonderful summer andhope you will enjoy the July 2007 issue of Senses.Victor ABDULLAH

Council NewsThe College Website, thanks to Dr M F Li and Dr Victor To, is now ready to serve you. When you have amoment, visit us at www.hkcorl.org.hk and do feel free to let us know how it can be further improved via ‘ContactUs’. You would have easy access to information on forthcoming events, CME guidelines, College Fact Sheetsfor operative procedures etc. You would even find ‘Senses’ on it. You can guess what might come next but,no, for now, it is much nicer to read a magazine with it in hand. In the password protected, login section;you would find a College Directory which is updatable. Please feel free to contact Miss Claudia Wong, ourCollege secretary for information on the login process. If you have not yet returned the form sent to you bythe College earlier, your information might not be present as the College does require your consent in postingyour information on this password protected section. A complete Directory of our Fellows and Members isalways helpful if and when we need to get in touch with a colleague. Claudia would be delighted to help youget your information, the amount you wish posted only, on the web.At the Hundred and Twenty Fifth Council Meeting, it was the consensus of the College Council, after carefulconsideration and deliberation, to recommend to the Medical Council that the Diploma DOHNS, Diploma inOtolaryngology-Head and Neck Surgery should not become quotable in Hong Kong. This decision was basedon the title itself and its training requirements in the light of our existing stringent regulations for the Diploma ofFellowship. The ultimate decision would rest upon the Medical Council.With great sadness, I report the loss of a senior surgeon of our ENT community Dr Low Keat Soo whopassed away peacefully in Canada earlier this year. I believe that only the most senior ENT surgeons wouldremember Dr Low who qualified in the early 1950s and was a Badminton Champion of HKU. Dr George Choaknew him well and worked with him when Dr Choa was a Medical Officer. Dr Low was in his eighties and ourcondolences go to his family.The Joint College and Society Trainee Presentation was held at the Regal Hong Kong Hotel on the 2ndDecember 2006. The Twelfth College AGM was held at 5:30 pm, at Room B1, Monaco Room of the RegalHong Kong Hotel. Minutes of the AGM have been posted on our website for your reference.Dr Chio Io Meng Dr John Chan Dr Lee Chi Leung Dr Wong Ka Chun

Dr Chio Io Meng and Dr Tang Man KaiDr John Chan and Dr Tang Man KaiDr Lee Chi Leung and Dr Tang Man KaiDr Wong Ka Chun and Dr Fung Kai BunThe George Choa Prize 2007 was awarded to Dr Chio Io Meng for her presentation on ‘Comparison betweenCocaine and Oxymetazoline in Flexible Nasoendoscopy’. The Hong Kong Society of Otorhinolaryngology,Head & Neck Surgery Prize 2006 was awarded to Dr Wong Ka Chun Justin on his presentation of ‘A HerbalFormula for the Treatment of Perennial Allergic Rhinitis: a Randomized, Double blind, Placebo-controlledClinical Trail. Many congratulations to the two and indeed to the rest of the presenters at the meeting, all ofwhom presented outstandingly.From the 6th-8th December 2006, Professor HeinzStammberger delivered a well-received lecturecourse on Functional Endoscopic Sinus Surgery inthree mornings. He was particularly enlightening tohear as he had witnessed the birth of the procedureto now as the procedure breaks barriers at the skullbase.Dr Chan Wing Kwan, Dr John Sung, Dr Dennis Lee, DrChan Hing Sang and Professor StammbergerProfessor Stammberger and Dr Fung Kai BunDr Yu Hip Cho, Dr Fung Kai Bun, Professer Stammbergerand Dr Luk Wai Sing

On the evening of the 7th, Professor David Eisele, George Choa Visiting Professor 2006 addressed ourCollege and spoke on Neoplasms of the Parapharyngeal Space, which was followed by dinner with ourFellows.Prof David Eisele and Dr FungKai BunProf David EiseleDr Chow Shun Kit, Dr Fung Kai Bun, Prof David Eisele, ProfYuen Po Wing and Dr Paul LamOn the 15th January, Professor Thomas Murry delivered a topical lecture on Spasmodic Dysphonia: Botoxand Surgical Management.Prof Murry Dr Paul Lam and Speech TherapistsDr Paul Lam and Prof MurryProf MurryOur College Conferment Ceremony and Scientific Meeting was held on the 21st April 2007.We had a most interesting scientific afternoon hearing about ‘Architecture and Our Health’ by ProfessorPatrick S S Lau and ‘Neuroendocrine Neoplasms of the Larynx: Advances in Identification, Understanding andManagement’ by Professor Alfio Ferlito from Udine, Italy.Prof Ferlito, Dr Fung Kai Bun,Prof William Wei and GuestDr Luk Wai Sing, Dr Chow Shun Kit, Dr Fung Kai Bun, ProfPatrick Lau, Prof Ferlito, Prof William Wei, Dr Tang Sho On andProf Yuen Po Wing

Prof Patrick Lau Prof Ferlito Dr Fung Kai Bun, Prof Patrick Lau and ProfMichael TongAt the Ceremony, Dr David Fang delivered the First Hong Kong College of Otorhinolaryngologists’ Orationtitled ‘The Role of the Medical Council, Past, Present and Future’. The College Oration will continue as ayearly event at the Conferment Ceremony.Dr David FangDr David Fang & Dr Fung Kai BunDr Herman Tang and Dr Fung Kai Bun presented the George Choa Prize and the Hong Kong Society ofOtorhinolaryngology, Head and Neck Surgery Prize to Dr Chio Io Meng and Dr Wong Ka Chun, Justin.Dr Chio Io Meng & Dr Tang Man KaiDr Wong Ka Chun & Dr Fong Ka Bun

Professor Patrick Bradley and Professor Alfio Felito were admitted as Corresponding Fellows of our Collegeat the Ceremony, Professor Bradley in absentia.Prof Alfio FerlitoProf Alfio Ferlito and Dr Fung Kai BunOur heartiest congratulations to our four new Fellows who were formally conferred Fellowship of our Collegeon the day, Dr Chan Wing Kwan, Anthony, Dr Ho Yee Man, Osan, Dr Wong Tak Cheung, Frederick and DrWong Yee Hang, Birgitta.The Council and New FellowsDr Chan Wing Kwan, Dr Wong Yee Hang,Dr Ho Yee Man and Dr Wong Tak CheungCollege Membership was conferred upon Dr Fung Tai Hang, Thomas, Dr Hung Che Wai, Terry and Dr TangChi Ho, Eric.Dr Fung Tai Hang and Dr Fung Kai BunDr Tang Chi Ho and Dr Fung Kai BunVictor ABDULLAH10

Report from the Censor-in-ChiefThe College CME/CPD guidelines for the next cycle starting January 2008has been finalized and is distributed together with this issue of SENSES.The revisions are introduced in accordance with the new Guidelines of theAcademy of Medicine. The two changes are points 3.2 and 5.2.Starting January 2008, a Fellow will only be accredited a maximum of 75CME/CPD points for “Passive Participation in Meeting” in a 3 year cycle. Theremaining 15 points are to be obtained from other CPD activities listed under5 (except 5.2).Hay Lap CHANLocalActivitiesDate Event VenueContactPersonMonthlyEvery Wednesday9:30 - 10:30amEvery Monday6:30pm- 7:30pmEvery Tuesday4:30pm-5:30pmEvery Saturday10:30am-11:30amEvery Tuesday4:30pm-5:30pm16-18 July 2007Group A18-20 July 2007Group B10-13 September2007 (1st round)Scientific MeetingJournal Club MeetingJournal Club MeetingJournal Club MeetingJournal Club MeetingJournal Club MeetingAdvanced Hands-on otology NeurologyDissection CourseAdvanced Hands-on otology NeurologyDissection Course5th Temporal Bone Dissection CourseSt Terasa's HospitalPWHPYNEHTMHYCHQEHCUHKCUHKCUHKDr. Tang Shu OnMichele ChanTel: 2632 3558Tel: 2595 6454Tel: 2468 5397Tel: 2417 8358Tel: 2958 6025Tel: 2632 3558Tel: 2632 3558Tel: 2632 3558OverseasActivitiesDateEvent Venue ContactPerson22 August200730-31 August200713 September200716-19 September20079-12 November200715-16 November200728-29 November200730 November -1 December200712the ASEAN ORL Head & Neck CongressInternational Comprehensive Head & NeckCourse 2007Endoscopic Course for Paranasal Sinusand Skull Base DurgeryAAO-HNS/F Annual Meeting & OTO Expo45th Art of Rhinoplasty Course8th International Symposium onMultidisciplinary management: the View ofCancer centres Throughout the World12th Asian Research Symposium inRhinology51st Annual Convention of the PhilippineSociety of Otolaryngology-Head and NecksurgeryHO Chi MingCity, VietnamChangsha,Hunan, ChinaBern, SwitzerlandWashington DCUSASan FranciscoCaliforniaAmsterdamNetherlandsPhilippinesPhilippinesEmail: drdungent@hem.vnn.vnWebsite: www.aseanorl2007.com.vnTel: (86) 731 4327 469Email: xyent@163.netTel: 0041 31 632 4174Email: marco.caversaccio@insel.orgWebsite: paranasal.swiss-meeting.orghttps://reg.jspargo.com/aao07Tel: 916 923 0820Email:rhinoplastycourse@sbcglobal.netWebsite: www.aafprs.orgEmail: hno@nki.nlWebsite: www.hooflhals.nki.nlTel: 632 436 6581Email: meet@ibahn.net.phTel: 632 436 6581Email: meet@ibahn.net.ph1212

Report from the Honorary TreasurerT he College finance remains healthy. Thereserve fund carried forward from the year 2006 isHK$1,856,178.09. At the 121st Council meetingon 23 January 2007, the Council had decided toallocate not more than 30% of the reserve fund forother forms if investment (including stock and bonds)instead of putting all our reserve in the fixed depositaccount. An Investment Subcommittee was set upto manage this investment fund in order to increasethe revenue return. Fellows and Members areencouraged to give their opinion and suggestions onour College investment to the subcommittee whichhas Dr. Fung Kai Bun, Dr. Luk Wai Sing and myselfas its members.TANG Shu On13

Famous People in OtolaryngologyLucja Frey - The Lady and her SyndromeDr Gordon SooDr Chan HSFrey’s syndrome - or gustatory sweating –whichamongst us has not heard of this condition ? Almostvery few if at all. Perhaps we know it because itis a relatively common “syndrome” of the headand neck region or maybe that it has a fascinatingpathogenesis. More likely than not, and probablycloser to the real truth, we know it off-by-hard simplybecause Frey’s syndrome is that frequently askedcondition in multiple choice questions, on clinicalward rounds and in those do-or-die viva voces. Buthere is something that not many of us may know –did you know that the condition was described by aneurologist by the name of Lucja Frey? And perhapseven more poignant are the circumstances thatsurrounded her life which makes memorable thoughsad and tragic reading.Dr Lucja Frey and her life would have been forgottenhad it not been for the eponym Frey’s syndrome.For various reasons, the history about her remainsobscure and scant. She lived in the years up untilthe Second World War. Much of the availablepersonal data and documentation were lost ordestroyed during the war. Surviving biographic dataabout Lucja Frey were mostly written in Polish andSwedish with few documentation of Frey’s tragic lifein the English literature. Sadly Lucja Frey did notsurvive the war years, falling victim to the GermanNazi regime of the time. It is therefore ironic thatit was the Germans who gave Dr Frey her bestbiographic publication in the English literature 1 .What follows below is an account of the life and workof Lucja Frey - and her contribution to medicine.LucjaFrey’sEarlyYearsLucja was born November 3, 1889 in Lwow, thenpre-WWII Poland, the daughter of a Jewish buildingcontractor. Lwow is today a Ukrainian city. She wasbought up in a non-orthodox Jewish family that hadbeen assimilated into Polish society. She graduatedfrom the State Girl’s High School on November 7,1907 to enter university.14

UniversityEducationIn her thirteen year period ofuniversity study (1907-1921),Lucja’s interest encompassedthe disciplines of Mathematics,Philosophy and Medicine. Shewas awarded her Degree inMathematics in 1912. Followingthis, she received her education inPhilosophy under the tutelage ofProfessor Marian Smoluchowski.Only in 1917, did she start studying medicine; Lucjawas by then twenty-eight years of age.In 1920, Lucja interrupted her study for a year andin her own words, “Because of the war betweenPoland and the Ukraine, I interrupted my studies fora year. In this time, I worked for Professor KazimerzOrzechowski in the State Hospital of Lwow.” LucjaFrey’s acquaintance with Professor Orzechowskiwas to prove crucial as not only did it substantiallyfurthered her professional development, butProfessor Orzechowski was one of the mostrenowned Polish neurologists of the time.HerGoldenYearsUnder the influence of Professor Orzechowski,Lucja Frey left Lwow and continued her medicaleducation in the University of Warsaw in 1921. Shewas awarded her medical diploma on June 2, 1923at the age of thirty-four. She excelled particularlyin neurology, psychiatry, pathology and generalanatomy and served at The University of Warsaw'sNeurology Clinic from 1921 to 1928. During thisperiod, Lucja published extensively. Her biographycontains 43 publications thatmainly focused on neurologicaldiseases such as Charcot’s joint,cerebral aneurysm and multiplesclerosis.Her first article, which wasregarding the description of Frey’s syndrome, was published inPolish andF r e n c h i n1 9 2 3 . D rLucja Frey’s scientific outputwas not large but yet each ofher work carried tremendousscientific weight which has lefta long and lasting mark on thescientific world.NewFamilyinLwowandtheAdventofWorldWarIIThe anti-Semitism fervor that was sweeping acrossEastern Europe drove Lucja Frey from Warsaw. Shereturned to her homeland in Lwow in 1929 whereshe became the Deputy Senior Consultant at theHospital of the Jewish Religious Commune in Lwow.Dr Frey married a lawyer, Marek Gottesman, in herforthieth year and gave birth to a daughter, Danuta,in 1930 2 .F r e y ' s D i a g r a min illustrating theauriculotemporalsyndromeLife was stable for the next ten years for theGottesman-Frey family until the German occupiedLwow in World War II. In 1939, Lwow was one ofthe most important centers for Jewish life in theworld where 32.6% of the 330,000 Lwow inhabitantswere Jews. Lwow was then taken over by Soviet15

Union in September 1939. Most of the Jews wereconsidered anti-communists because of theirprofessional identity. Lucja Frey’s husband Marekwas accused of counter-revolution and was arrestedand executed by the Soviet Communists.In the flow and ebb of thetides of war, Lwow was reoccupiedby Germany in June1941 during the war. Lwowsoon became a Jewish ghetto.Her Jewish population wasdivided into “useful” and “nonuseful”categories. The firstbatch of “non-useful” Jewswas sent to the death campin Belzec in March of 1942. Being a physician, Freywas considered as a “useful” Jew. She was issued aGreen Card with the number 144 inscripted.L u c j a F r e y ' sregistration as ahealth professonalduring WWII issuedb y t h e G e r m a nNazi GovermentTheLegacyofLucjaFreyMany of wars casualties are usually sadly forgotten.How shall Lucja be remembered?For Dr Lucja Frey – outstanding scientist, femmeextraordinaire, physician of distinction – hermemory will continue to live on through her work,either consciously or unconsciously, in the mindsof medicine. She will always be remembered byavid medical historians, on those most mundanemoments of our profession at the teaching clinicalrounds, at medical student tutorials and at thosestressful examinations simply because of two words.These two words that bear her legacy to our worldof medicine and to the memory of her life - Frey’ssyndrome.DrLucjaFrey’sImportantContributiontoGustatorySweatingShe continued to look after Jewish patients at thelocal ghetto clinic until August 1942. By then, Lucjahad lost her usefulness to the authorities in power.On a fateful 20th of August, 1942, the ghetto clinic’s medical staffs were all shot, together with theirpatients – records showed that at least 400 peoplewere murdered.By the end of the WWII, only 823 of the original250,000 Lwow Jews survived. Noevidence remains to show that DrLucja Frey or her family memberssurvived the war. Like many ofher Lwow Jewish community thatshe served, Lucja Frey was anunfortunate victim of WWII.Frey in 1941-probably herlast photoBefore Frey, various notable authors had describedthe phenomenon of gustatory sweating followingsurgical drainage of parotid abscesses. Most of them,however, were describing traumatic salivary fistulaesequelae rather than true gustatory sweating 3 .Duphenix, 1757 - described the first caseof “gustatory sweating” which was later believed tobe a case of traumatic fistula.Dupuy, 1816 - discovered the effect of sectioningcervical sympathetic and its effect on gustatorysweating in a horse.Baillarger, 1853 - documented 2 cases of typicalgustatory sweating in a human patient. Baillargerinterpreted the facial fluid as saliva as a result of16

a blocked Stensen’s duct. Although his conclusionof the pathology was incorrect, the delay onsetand persistence of symptoms suggested genuinegustatory sweating.Brown-Sequard, 1850 - was the first physician touse the term “facial sweating”. This helped futureauthors to better understand the nature of the fluidobserved in this condition.only by sweating but also flushing of cheek. Frey’ssyndrome can also be demonstrated in 90% of postparotidectomypatients with the onset usually at 6weeks to 3 months after surgery. Of these gustatorysweaters, only 10% are symptomatic enough towarrant further treatment.New and Bozer, 1922 - reported on 3 cases of“Hyperhydrosis of the cheek associated with injuryto the parotid region”.Lucja Frey, in 1923, gave the most detailedand correct description of the symptoms 4 . Shewas the first to define gustatory sweating as adisorder of both sympathetic and parasympatheticinnervations. She correctly stated that parotidsecretion was controlled by the glossopharyngealnerve and sympathetic nervous system. Usingdifferent pharmacological agents, Frey identifiedthe auriculotemporal nerve as responsible for thesyndrome and argued that it was the missing linkbetween eating, gustatory stimulation and thephenomenon of facial sweating.To d a y w e k n o w F r e y ’s s y n d r o m e t o b e aphenomenon of aberrant nerve regeneration afterparotid injury as a result of misdirected regenerationor collateral sprouting of parasympatheticfibers into vacated sympathetic pathway in theauriculotemporal and nearby nerves 5 . With time,functional connections between parasympatheticsecretomotor, sympathetic dennervated sweatgland and cutaneous blood vessels becomeestablished such that salivation is accompanied notMain train station, LwowVarious surgical techniques are available to reducethe incidence of Frey’s syndrome though noneare convincingly effective. Tympanic neurectomyof Jacobsen’s nerve may be initially effective inabolishing Frey’s syndrome, but the nerve position isvariable and it is associated with a high recurrencerate. Today intradermal injection of botulinum toxinA is probably the most efficacious and long-lastingtreatment for treating Frey’s syndrome 6 . Lucja, theneurologist, would indeed be most intrigued.References1. M. Moltrecht, O Michel , The woman behind Frey’s syndrome:The tragic life of Lucja Frey.. Laryngoscope 114, Dec 2004:2205-22092. Bennett JD, Frey’s syndrome: The untold story. J Med Biogr1993,1:125-1273. Dulguerov et al, Frey Syndrome before Frey: The correcthistory:. Laryngoscope 109, Sep 1999:1471-14734. Frey L. Le syndrome du nerf auriculo-temporal. Rev Neurol1923, (II): 97-1045. P D Drummond , Mechanism of gustatory flushing in Frey’ssyndrome: Clin Auton Res (2002) 12: 144-1466. Abigail Arad-Cohen, Andrew Blitzer, Botulinum toxin treatmentfor symptomatic Frey’s syndrome: Otolaryngol Head Neck Surg2000,122 (2): 237-23917

Hospital TourHong Kong Sanatorium & Hospitalshow them all to you as that would need the wholevolume of Senses! Let me pick out some of theshowpieces for you.Having shown you around in a hospital in the H.Alast time, it is turn for the private sector. The HongKong Sanatorium & Hospital, considered to be anultra modern hospital and one of the best, if not thebest, private hospital in Hong Kong, would be aperfect choice to start my mission.The Plastic & Reconstructive Surgery Centre isfully equipped with operating theatres and laserrooms for day surgeryand laser treatment.Patient privacy andcomfort are ensured bythe individual waitingrooms.Waiting for rejuvenationIt was a rainy afternoon when I arrived at the lobbyof the Sanatorium where I received the warmestwelcome by Dr. Patrick Wong, the assistant medicalsuperintendent, and Dr. William Yip, the consultantENT Surgeon.Dr. Yip and the friendly staffDr. Patrick Wong & Dr. William YipThe Department ofHealth Assessmenti s w e l l e q u i p p e dw i t h t h e s t a t e - o f -the-art facilities andequipment. PatientsPlace to keep you healthyare provided with a one-stop service of check-upprogram with health assessment, a wide range ofinvestigations and counseling.You can find the cutting edge of nearly all aspectsof the medical field in the Sanatorium. I can’t reallyThe Sanatorium is renowned for its ophthalmologyservice which is provided by a full team of18

ophthalmologistso f v a r i o u ss u b s p e c i a l t i e s .Guy Hugh ChanRefractive SurgeryC e n t r e h a s atremendous volumeo f L A S I K a n drefractive surgeryperformed. Theseh e l p p a t i e n t s t oenjoy better vision with less dependence on glasses.The quiet and comfortable environment undoubtedlymakes the experience of having surgery a morepleasant one.LCD right in front of youLying in bed on the wardis invariably unpleasant.H o w e v e r, h a v i n g atelevision right in frontof you and access tob r o a d b a n d i n t e r n e tservice definitely canrelieve the anxiety. Thesafe by the side givesa d d i t i o n a l s e n s e o fsecurity. Needless tosay, the deluxe private room and suite might justgive the illusion of spending a few days in a holidayresort if one can afford it.Wealth on the bed, moneyin the safePlace to throw away your glassesOnly the suction gives youthe hint it is a wardR a d i o l o g y i sessential in ourpractice. In theSanatorium, yousee the forefronto f m e d i c a li m a g i n g . T h estate-of-the-artDual Source CT, being the fastest scanner available,the high definition MRI (1.5 & 3T) scanners andthe upfront PET/CT simply provide details with thehighest sensitivity.Opening up the body is part of our job as a surgeon.It can be done by robots here! Just kidding! Thelatest model of da Vinci S Robotic Surgical Systemis available this year. Although it is not widely usedin the ENT at the moment, the robotic-assistedtechnique may possibly be the next step in minimalinvasive surgery in our field.T h e E N T s e r v i c e i scomprehensive and costeffective.As describedby Dr. William Yip, theENT clinic is “minimallyi n v a s i v e ” , b o t h t ot h e h o s p i t a l b u d g e tand patient’s pocket!Everything in the roomi s p r a c t i c a l .P a t i e n t s c a nh a v e t h ehearing test andnasopharyngealbiopsy in thes a m e r o o m .T h e y t h e nA busy table in RadiologyEverything you need is there19

wait in the quiet seating area for the frozen sectionresult. If further oncologist’s opinion is needed, theywill be guided to the oncology centre promptly. Theindividual waiting area outside each consultationroom in the oncology department provides maximumprivacy and comfort to patients and their familymembers.Short Interview with the MedicalSuperintendent,Dr.WaltonLihappy,” he said “and they will take pride in theirprofession.”I was curious about the secret of success inmanaging the hospital. Dr. Li said,” The managersall came from the medical frontline and so they knowexactly what the patients need. Within the hospitalsystem, bureaucracy is cut down. We have regularstaff meetings and retreats for direct communicationand decision making”Dr Wai Kin Hang and Dr Walton LiHaving walkedt h r o u g h ahospital of the“ M e r c e d e s ”c l a s s , Iw a s t o t a l l yimpressed noto n l y b y t h equality of themedical equipment and facilities, but also by thecozy and friendly atmosphere within the hospital. Isaw smiles from patients as well as staff. I was alsogiven an invaluable chance to interview the MedicalSuperintendent, Dr. Walton Li.How is the friendly atmosphere achieved andmaintained? “The 3 “T”s – Teaching, Teamworkand Trust” was Dr. Li’s response. He elaboratedthat doctors should take up the roles of teachingthe nurses and staff for patient care, which is ofparamount importance. The staff members worktogether as one team. Trust among team membersis vital to ensure close collaboration and crosscoverage. Dr. Li also emphasized the importance ofthe nursing staff since they have the most frequentcontact with patients. “We need to keep the nursesAs for the future development of the hospital, Dr.Li replied that they would aim to become a medicalhub world wide. “Our hospital provides a platform foreducation and academic activities at the internationallevel. If you can come up with new technology andadvancement which is beneficial for patients’ care, Iam always happy and willing to introduce that to thehospital.” So, Members and Fellows, think laterallyand step forward!Even another few thousand words would not be ableto describe all that I had seen in this hospital visit,not to mention the Phase III development and the85th anniversary events. Last but not least, I wouldlike to thank Dr. Walton Li, Dr. Patrick Wong andDr. William Yip for their precious time showing mearound. It was truly an enjoyable tour.Talen WAIDeclaration of competing interests: none declared20

The Journal ClubThe Role of ENT Surgeons in DermatomyositisD e r m a t o m y o s i t i s i s a nu n c o m m o n a u t o i m m u n edisease. The incidence inUSA is about 1 to 10 casesper million, within which itsoccurrence in female is twicemore common than male.With advanced immunosuppressive therapy, themortality rate related to this inflammatory diseaseor its treatment is less than 10% in developedcountries. Most patients with dermatomyositis,however, really succumbed to the malignancyassociated with dermatomyositis rather than thedisease itself. The risk of developing malignancyin dermatomyositis is 6.5 times compared with thenormal population; the highest risk group are thosepatients over 45 years old. (Ric Anthony Koler et al.2001)To reduce the mortality rate of dermatomyositisamong patients, extensive screening of the occultmalignancy for early intervention is of utmostimportance. The first report of dermatomyositisassociated with stomach cancer was published in1916; subsequent reports showed that this diseasecould be associated with breast cancer. Thepathogenesis of cancer is believed to be caused bythe impaired cell-mediated immunity in autoimmunedisease. Most common malignancies associatedwith dermatomyositis in Caucasian countries areovarian cancer, stomach cancer and lymphoma. Inview of this, cancer screening of dermatomyositispatients in some western countries includingbaseline Ca125 and regular gynaecologicalexamination every 6 months for a period of at least2 years. Experts in western countries also considerthat the female gender in dermatomyositis is a poorprognostic factor in developing cancer.Does the same disease pattern apply to theChinese population? Although the incidence ofdermatomyositis in Chinese woman is similar tothat in western countries, with the disease itself 2to 3 times more common in female compared tomale, the gender risk factor in developing cancer isfound to be male dominant rather than female. Therisk of male dermatomyositis patients developingcancer is 2.5 to 4 times more than that of femalepatients. The predominant cancer is also differentfrom Caucasian. There are different reports fromMainland China, Hong Kong, Singapore and Taiwan,showing that the commonest cancer associatedwith dermatomyositis in Chinese population isnasopharyngeal cancer. (Hu,Wei-Han et al. 1996)The low incidence of dermatomyositis in Caucasianalso applied to Chinese, e.g. the incidence foundin Singapore is only 7.7 cases per million per year.An estimate of 20 to 41% Asian dermatomyositispatients was associated with cancer, and mostcancer was declared within one year afterdiagnosis of dermatomyositis. However, delayedpresentation of malignancy up to 2 to 4 yearshad been reported. Among all these cancers,22

25% to 80% is associated with nasopharyngealcarcinoma (NPC), which became the commonestcancer associated with dermatomyositis in Chinesepopulation. In one Hong Kong report investigatingthe relationship of NPC with dermatomyositis, 10%of NPC cases presented before the dermatomyositisbut most declared itself after the first diagnosis ofdermatomyositis, with an average interval of eightmonths. One Taiwan study reported that the oddratio of NPC in dermatomyositis is 8.0 comparedwith that of the normal population. Three strongestpredictive factors were found to have contributionin developing cancer in dermatomyositis, they are:older age (>45 years), male gender and high CPKlevel at the time of presentation. (Chen et al. 2001)One Hong Kong local report of six patients withamyopathic dermatomyositis (one category ofdermatomyositis without muscle features) found thatall 5 male patients developed cancer (3 NPC, 1 lungcancer, 1 cervical metastasis of unknown primary),but the single female case was free of malignancy.This paper also stressed the importance of NPCscreening in dermatomyositis. (Fung et al. 1998) Ifthe patient is a male, extensive screening and closemonitoring is justified. Although one report fromJapan described the survival rate of dermatomyositispatients associated with cancer dropped to 10%at 5 years, this result may not appliable to HongKong since this Japanese series contained mainlyCa uterus, Ca lung and Ca stomach, with not asingle case of NPC. (Nobuo Wakata et al. 2002).The prognosis for NPC is considered to be betterespecially if we can detect the cancer at an earlystage.Nowadays, the advanced technology in radiotherapyand chemotherapy could help cure more than 90%of stage 1 NPC patients. But if the cancer presentsas stage 4, the cure rate drops to 58%. (AnneW.M.Lee et al. 2005) This stressed the importanceof NPC screening in this group of patients in order topick up this disease at its earliest stage.As a conclusion, dermatomyositis is a rare disease;however ENT surgeons have an important role inperforming early cancer screening. Since mostNPC developed within 1 year after first diagnosisof dermatomyositis, regular endoscopic screeningup to 2 years is justified especially if the patient isa male. More extensive investigations like PET-CTmay also be considered if resources are available.Gerald Ka Lak KAMReferences ListAgnes Sparsa, Eric Liozon, Francois Herrmann, Kim Ly, ValerieLebrun, Pascale Soria, Veronique Loustaurd-Ratti, Marie-LaureBouyssou-Gauthier, Serge Boulinguez, Christophe Bedane, Marie-Odile Jauberteau, Elisabeth Vidal, Jean-Marie Bonnetblanc (2002)Routine vs Extensive Malignancy Search for Adult Dermatomyositisand Polymyositis. Arch Dermatology, Vol 138, July 2002, 885-890Anne W.M.Lee, W.M.Sze, Jose S.K.Au, S.F. Leung, T.W. Leung,Daniel T.T.Chua, Benny C.Y.Zee, Stephen C.K.Law, Peter M.L.Teo,Stewart Y.Tung, Dora L.W.Kwong, W.H.Lau. (2005) TreatmentResults for Nasopharyngeal Carcinoma in the Modern Era: TheHong Kong Experience. Int. J. Radiation Oncology Biol. Phys.,Vol.61, No.4, 1107-1116Hu,Wei-han; Chen,De-lin; Min,Hua-qing (1996) Study of 45 Casesof Nasopharyngeal Carcinoma with Dermatomyositis. AmericanJournal of Clinical Oncology, Vol 19(1), Feb 1996,35-38Nobuo Wakata, MD, Teruyuki Kurihara, MD, Eizo Saito, MD, andMasao Kinoshita, MD. (2002) Polymyositis and dermatomyositis23

associated with malignancy: a 30-year retrospective study. InternalJournal of Dermatology, 41, 729-734Ric Anthony Koler, Andrew Montemarano (2001) Dermatomyositis.American Family Physician, Vol 64, 1565-1572S.M.Sultan, Y.Ioannou, K.Moss and D.A.Isenberg (2002) Outcomein patients with idiopathic inflammatory myositis: morbidity andmortality. Rheumatology, 41:22-26Wai Kit Joseph Fung, Hin Lee Henry Chan, Wai Man Wynnie Lam(1998) Amyopathic dermatomyositis in Hong Kong – association withnasopharyngeal carcinoma. International Journal of Dermatology,37, 659-663Y.J.Chen, C.Y.Wu, J.L.Shen (2001) Predicting factors of malignancyin dermatomyositis and polymyositis: a case-control study. BritishJournal of Dermatology, 144, 825-831Nose replantation following a dog bite injuryDog bite injury of the nose isan emergency condition that isdifficult to treat. The wound isusually contaminated, irregularand associated with extensivesoft tissue loss. The authorsd e s c r i b e d a s u c c e s s f u lreplantation of an amputated nose after a dog biteinjury. The amputated segment was appropriatelyhandled and transported, and an operation involvingtissue debridement, microvascular anastomosisand suturing was done. A branch of the dorsalnasal artery and two veins were anastomosedwith 10/O nylon. Meticulous management of thereplanted nose started in the recovery room, whichinvolved application of leeches, infusion of heparinand prescription of aspirin and levofloxacin. Theaesthetic result was excellent judging from thephotographs, and the functional result was alsogood. However, it is important to note that sucha result could not possibly be achieved without awhole team of highly trained and dedicated medicalstaffs, including ambulance men, nurses andmicrovascular surgeons.Frederick WONGSuccessful replantation of an amputated nose after dog bite injury. RL Flores, N Bastidas, R D Galiano. Otolaryngology-Head and NeckSurgery. 2007; 136: 326-327.Near Real-time Navigation for FESSIt is called near real time navigation because itmakes use of a fluoroscopic scanning method toupdate the CT images right before and during theoperation. The fluoroscopic images were obtainedby a C-arm around the operating table, and thedata were then loaded into the computer andincorporated into the pre-op scans to generate CTlikeimages. Like the traditional navigation system,these images allowed 3-dimensional navigationduring the operation. This system had been testedin previous cadaveric study, and the authors wouldlike to study its usefulness in operations. FESS24

was performed on 14 patients with this technologyand the experience reported. All 14 operationswere successful and immediate post-operativefluoroscopic images showed adequate clearanceof disease. The limitations and precautions ofthis method were identified, which include mobilityproblems of the C-arm, the need to work aroundthe transmitter which was glued to the headset,and the distortion of images by blood and nasalpacking. The last problem was especially difficult toresolve and it made it difficult to assess the extentof residual soft tissue diseases. That explains whythis technology is more useful for bony pathologyat present. Additional time expenditure was lessthan 10 minutes per scan, and additional radiationexposure was about 12% of a standard CT per scan.The cost was not mentioned in the article. Morestudies are needed to show more superior outcomein terms of disease clearance and complicationrate to justify the additional cost, time and radiationexposure. This is also acknowledged by theauthors.Frederick WONGFeasibility of near real-time image-guided sinus surgery usingintraoperative fluoroscopic computed axial tomography. S M Brown,B Sadoughi, H Cuellar, R von Jako, M P Fried. Otolaryngology –Head and Neck Surgery 2007: 136: 268-273.Naganuma H, Kawahara K, Tokumasu K, Okamoto M.Water may cure patients with Meniere Disease.Laryngoscope 2006;116:1455-60This is the first systematicreport and an interesting studyon the effectiveness of waterintake therapy in the treatmentof Menieres Disease. Theauthor postulated that bylowering the plasma ADHlevel after increase in water drinking will decreasethe secretion of vasopressin and normalize waterpermeability in the inner ear. The study consisted of2 groups of patients. Group 1 patients drank 35ml/kg of water per day in addition to the normal dailybeverages and food for 2 years. Group 2 patients,the control group received the conventional therapyof 63g/day isosorbide as diuretic and 75 mg/daydiphenidol hydrochloride as antivertiginous drug.Results showed that patients on water therapyhad significant relieve in vertigo and improvementin hearing compared to those on conventionaltreatment.This paper suggests that water therapy may bea possible therapeutic modality for treatment ofMenieres. Further large scale studies or randomizedcontolled trials should be conducted.Birgitta WONG25

Robotic Surgery in the Pediatric AirwayRahbar R, Ferrari LR, Borer JG, Peters CAArch Otolaryngol Head Neck Surg. 2007;133:46-50Robotic surgical systems have been used inurologic, cardiac and thoracic procedures. Thisstudy was to evaluate the application, efficacy andsafety of the da Vinci Surgical Robot in the pediatricairway. The Robot was used on 4 cadaveric larynxesand 5 pediatric patients with laryngeal cleft. Resultsshowed that robotic surgery on cadaver larynxesallowed the surgeon great dexterity and precision,delicate tissue handling, good 3-dimensional depthperception and easy endolaryngeal suturing. Theauthor further demonstrated success in transoralrobotic repair of laryngeal cleft in 2 patients. Limitingfactors of robotic surgery in children lie on the sizeof the equipments and limited transoral access. Withfurther advances in the device and development ofsmaller instruments will certainly facilitate Roboticsurgery in this field.Birgitta WONGHow I do it: Endoscopic ligation of anterior ethmoidal arteryW hen severe epistaxisdoes not respond to nasalpacking, endoscopic ligationof the sphenopalatine arterywould be performed prettycommonly now. However,bleeding may not be controlledif the bleeding site is too high or too anterior in theregion supplied by anterior ethmoidal artery (AEA).Treatment options include an external approachto ligation of the anterior ethmoid artery andembolization. However, the former will create a facialscar and latter may result from blindness and stroke.The author shared his experience on how to ligatethe AEA endoscopically even the AEA is encasedwithin a bony canal in skull base. The first surgicalstep is to perform maxillary antrostomy to identifythe level of the orbital floor. The bulla ethmoidalis isresected and anterior ethmoid cells are cleared toexpose the medial orbital wall and ethmoidal roof.A 30° endoscope is then used to visualize the bonycanal of AEA. A small opening is made through thethin bone of the lamina papyracea just inferior to thecanal. Care is taken to avoid injury to the underlyingperiorbita. Bone fragments are elevated andremoved to expose the AEA as it enters the ethmoidcavity from the orbit. A periosteal elevator is used toelevate anteriorly, superiorly and posteriorly to theAEA in order to provide an adequate exposure forvascular clipping. After the vessel and its overlyingfascia have been isolated, an angled clip applieris used to ligate the artery. The author performed26

in three patients with concomitant endoscopicligation of both sphenopalatine arteries and anteriorethmoidal arteries for epistaxis. Bleeding wasstopped and the patient can be discharged the nextday. Although the feasibility had been demonstratedby the author, it may not be easy when the operativefield is bloody during epistaxis.Dennis LEEPletcher, Steven D. MD; Metson, Ralph MD Endoscopic Ligation ofthe Anterior Ethmoid Artery. Laryngoscope. 117(2):378-381, February2007.Bilateral vocal cord paralysis caused by laryngeal mask airwayTransient or permanent vocal cord paralysis hasbeen repeatedly reported as a complication ofendotracheal tube insertion. The laryngeal maskairway (LMA) is regarded as a safer technique inrespect to this complication. Kazuhira reporteda case of bilateral vocal cord palsy after usingLMA, which required tracheotomy to secure theairway. Surgery over the patient’s left shoulderwas performed under general anesthesia. Size 3LMA was uneventfully inserted and anesthesia wasmaintained with nitrous oxides and sevoflurane. Cuffwas inflated with 20ml of air and pressure was notmonitored during anesthesia. The surgery lastedfor 425 minutes. The patient noticed difficulty inbreathing two hours after the operation. Flexiblelaryngoscopy revealed bilateral vocal cord palsy withedema of the bilateral arytenoids and aryepiglotticfolds. Tracheotomy was performed. CT scan showedno signs of arytenoids dislocation or neurologicalcompression. Bilateral vocal cords became mobile 4weeks afterwards. The author comment that bilateralvocal cord palsy in this case can be due to pressureneuropraxia by the over-inflated cuff secondary tonitrous oxide diffusion into the cuff. It is well knownthat the cuff pressure in LMA increases duringgeneral anesthesia because of diffusion of nitrousoxide across the semipermeable membrane of theLMA tube cuff. Other theories including arytenoiddislocation, diffusion of lidocaine jelly applied to thecuff, compression of recurrent laryngeal nerve atthe apex of the pyriform fossa and misplacementof the LMA tip between the false cords had beendiscussed. The author also suggested guidelinesto avoid this complication: (1) standard insertiontechnique, (2) using large LMA to decrease the cuffpressure, (3) monitor the LMA cuff pressure and (4)pay attention to any signs of malposition.Dennis LeeBilateral vocal cord paralysis caused by laryngeal mask airway.Endo K, Okabe Y, Maruyama Y, Tsukatani T, Furukawa M. Am JOtolaryngol. 2007 Mar-Apr;28(2):126-9.27

Overseas Courses and AttachmentsVisit to the Great Ormond Street Hospital, Londonchildren’s health care, currently delivering the widestrange of specialist care and paediatric research.The Paediatric Otolaryngology unit at GOSis famous worldwide for airway and laryngealreconstruction, complicated ear reconstruction,osseointegrated techniques, cochlear implantationand management of other congenital abnormalities.There are 4 consultants including Mr Martin Bailey,Mr David Albert, Mr Benjamin Hartley and MsMichelle Wyatt, all renowned in the field of ENT.Great Ormond Street Hospital entranceLondon has always been the premier city inEurope. Not only is it home to familiar landmarks asBig Ben, Tower Bridge, the glorious River Thamesand now the London Eye, it also boasts the greatmuseums, art galleries and more theatres than anyother parts of the world. Between April and June2005, I had the opportunity to undertake a visitingobservership at the Great Ormond Street Hospital(GOS) in London which is part of the Institute ofChild Health of the University College London.During the 3-month visit, I had a plentiful ofopportunities to observe a wide variety of operationsincluding laryngotracheobronchoscopy, difficultlaryngotracheal reconstructions, opening of choanalatresias, excision of branchial fistulas, bilateralcochlear implantations and BAHA. Being a tertiaryreferral centre, I had seen difficult paediatric headand neck cases such as excision of cystic hygroma,thyroidectomy for extensive papillary carcinoma andeven facial nerve grafting in a 5-year-old boy afterThe hospital was founded in 1852 as the firstchildren hospital in UK, situated at the convenientRussel Square of Central London. It is a nationalcentre of excellence in the provision of specialistDr Birgitta Wong with Mr Martin Bailey28

excision of a huge teratoma of the face.Apart from traditional operations, Mr Bailey and otherconsultants were gracious enough to demonstrateGarden. Transport systems fan out well fromLondon and almost nowhere is impossibly far fromthe capital. I have spent weekends in excursionssuch as the mysterious, impressive Stonehengewhich was thought to be astronomical observatorysites or temple for worship of ancient earth deities.The City of Bath is unique with its stunning hotsprings and ancient Roman baths. Oxford, beingthe City of Dreaming Spires, is famous for its superbarchitecture and strong atmosphere of academicexcellence.Dinner with the ENT registras and visitorsand share their new techniques to all visitorsfrom different parts of the world. I had observedthem performing dilatations of subglottic stenosiswith vascular balloons; injection and instillationof Cidofovir for treatment of recurrent respiratorypapillomatosis and open submucosal resectionof subglottic haemangioma with very successfulresults. Even simple surgery, I was impressedby the efficient, clear and bloodless technique ofadenoidectomy with the use of suction diathermy.Besides operations, I attended special clinics likethe combined cleft clinic, cochlear implant clinicsand research meetings which benefited me muchin future management of complicated paediatricpatients.To conclude, I really had a memorable and fruitfulvisit in London. I treasure the time in GOS observingexperts operating and I miss all the musicals andFriday evenings spent with the friendly registrarsat pubs which I had never thought of even comingclose to.The ancient Roman bath at City of Bath, unchanged formore than 2000 years!April to June is a good time to stay in London asspring comes with lovely warm spells and brightclear days. It will be nice to spend a Saturdayafternoon at Hyde Park and relax amongstthe meadow, trees and lakes; or to watch liveperformances and street entertainers at CoventTo w e r B r i d g e o n R i v e rThamesThe mysterious StonehengeBirgitta WONG29

4th Biennial International ‘Milano Masterclass’Sinonasal & Skull Base Endoscopic Microsurgery, March 23-25, 2007Rhinoplasty & One Pearl of Facial Plastic Surgery, March 25-27, 2007Professor plama and Professor Paolo CastlnuoroThe 4th Biennial International “Milano Masterclass”On Endoscopic Skull Base Surgery and Rhinoplastictechniques in March 23-25 2007 deserves a goodmention. I, of course attended it funded by HA withsome skepticism as to how much I would be ableto really gain from a double bill conference likethis. Much to my surprise, in the midst of heavy jetlag having crumpled up in ‘purgatory’ (pardon myexpression though it felt that way), last row of therear cabin on Cathay (not really complaining aboutmy parsimonious organization), I was glued to mychair all the way through the program, oh, perhapsexcept for a short visit to the Duomo on the Sundaywhich was a great experience.The speakers were the very best and they were allgood friends who did it to teach and not for show.It was impressive to see that what we used to fear,CSF leak, carotid bleed etc. were no longer issuesat which point the brain did not seem to be the limit.I wonder what next. The four handed techniquesfor tumor resection and ENT/Neurosurgery with thecorrect instruments, now widely available, was apleasure to watch on video (no live surgery). I mustsay I could not really follow the intraclival anatomy,though well demonstrated with the endoscope, Ibelieve, by the brilliant anatomist Dr Tschabitscher.Paolo Castelnuovo and the Pittsburgh groupRicardo Carrau and Amin Kassam brought genuinenew insight into what was relatively non-invasivelypossible with the nasal endoscope.The Course Faculty Toasting and Singing 'Volare' ('to fly') atthe banquetThe rhinoplasty part which I enjoyed very muchwould appeal to our colleagues who take an interestin the field but not everyone. The slant was thepractical approach to it all. Practical analysis andtricks and maneuvers (there are so many of them!)to achieve specifics by the top guns in Rhinoplastic30

surgery. What works and how well it does afterten years were most succinctly presented. Theprocedures are not irrelevant to HA practice asthere are the traumatized noses and the Cleft andcongenital deformities. There are many who havebeen longing for some help, much to my surprise,when one looks.course dinner venue. It may be best to travel at leastWorld Traveler Plus BA, Oasis Business or upgradeto Business with others with your miles (This appliesto HA employees only!). I thought it would be OKwith economy but had to conclude that my age wasadvancing.Victor ABDULLAHThe 4th Biennial Milano MasterclassThe shopping at nearby Duomo had to be doneon the morning before I flew off. You keep gettingtold by the brilliant Surgeon and Course DirectorProfessor Pietro Palma on the big screen: “Youare not on holiday!”. The course goes from8:30am- 7:00pm every day! The course is highlyrecommended for specialists who have pretty wellseen a good cut of the clinical spectrum yet yearningfor something more. The next course will be heldin 2009. Ladies, don’t bring your husband to theMilan conference! He will be bored. Gentlemen, ifyou bring your wife, she will have a wonderful timebut may go wild in the midst of an overwhelmingselection of the latest in Italian fashion. TheConference Hotel this time was six short stops fromMilan centre. My recommended restaurants in theevening in Milan would be Al Penny, Da ILia and the31

Books, Articles and websiteson occasions lethal. Therefore, there is a continuedsearch for efficacious yet less toxic alternative.The epidermal growth factor receptor (EGFR) isabnormally activated in epithelial cancers, includinghead and neck cancer. Studies had shown thatblockade of EGFR signaling would enhances thecytotoxic effects of radiation. Cetuximab (Erbitus,ImClone Systems), an IgG1 monoclonal antibody, isone such agent.In this issue of Senses, rather than websites andBooks, I would like to report on an article publishedin the The New England Journal of Medicine(February 2006; 354(6):567-578):Radiotherapy plus Cetuximab for Squamous CellCarcinoma of Head and Neck.Authors: Bonner, James A, Harrari Paul M, GiraltJordi, et al.This study was supported by ImClone systems,Merck (Darmstadt, Germany) and through a grant(CA06294) from the National Institues of Health.BackgroundThe management of loco-regionally advanced headand neck cancer has undergone a major shift duringthe past 2 decades. For advanced resectable tumorsof hypopharynx and oropharynx (and larynx in somecenters), chemoradiotherapy has assumed a majortreatment role. This is because it allows organpreservation,usually better post-treatment function,but without jeopardizing the survival. However, thetoxicity of chemoradiotherapy is often severe andWhatisthisstudyabout?Patients with loco-regionally advanced (stage IIIand IV) head and neck squamous cell carcinoma(oropharynx, hypopharynx and larynx) wererandomized to receive high dose therapy alone (213patients) or high dose radiotherapy plus weeklyCetuximab (211 patients). The outcome measuredincluded loco-regional control, overall survival,progression-free survival, the response rate andsafety.Whichtreatmentgroupachievedbetterresults?(analysed on intention-to-treat basis)Only the first 3 years of results were available. Thecombined radiotherapy/ Cetuximab group (RT/Cetux) yielded statistically significant superior resultsin all parameters of tumor control and survival whencompared to that of the radiotherapy alone group(RT).Size of the benefit?At 3 years, the RT/Cetux group achieved a/an1. locoregional control rate of 47% (versus 34% inRT group)33

2. overall survival of 55% (versus 45% in RT group)3. progression-free survival of 42% (versus 31% inRT group)The overall response rate (the rate of completeand partial responses) for the RT/Cetux was 74%versus 64% in RT group, which is also statisticallysignificant.ToxicityofCetuximabAmong the 211 patients who received cetuximab,13 required discontinuation. Four of them were dueto hypersensitivity reactions and eight other werebecause of a grade 3 acneiform rash. Less than5% of patients required a dose reduction. Notably,Cetuximab did not exacerbate the common toxiceffects of radiation.This editorial also remarks that:“Despite the lack of comparative studies, oncologistsshould keep in mind that all studies of platinumbasedchemoradiotherapy have shown greaterimprovement in patients than Bonner found withcetuximab”Isthereaplaceforcetuximab?With current evidence, for those advanced cancersthat are treated non-surgically, chemotherapy withcisplatin remains the standard of care. Patients whocannot tolerate chemotherapy may benefit from theaddition of cetuximab to radiotherapy.There are on-going studies to see whethercetuximab can be added to chemotherapy to furtherenhance the treatment outcome.Howshouldweinterprettheseresults?A good discussion about this paper could be foundin the Editorial of that journal issue by Posner andWirth. (Cetuximab and radiotherapy for head andneck cancer. N Eng J Med;354(6):634-6)Siu Kwan NGThe reported gain in survival without a substantialincrease in toxicity by adding Cetuximab in thetreatment regime certainly sounds attractive.However, one should take note that these areonly early results of up to 3 years. The result maybe significantly worse on longer term follow up(say, at 5 year), which was the experience shownon a European chemoradiotherapy trial. Also theimprovement in survival in RT/Cetux group wasevident for oropharyngeal cancer but not amongpatients with hypopharyngeal and laryngeal cancer.3434

CPD QuizCase1A 3 8 y e a r o l dg e n t l e m a npresented with avery husky voicefor two years. Heunderwent multiplemicrolaryngoscopic procedures but the lesionhad a relentless propensity for recurrence.Videostroboscopic examination of the larynxdemonstrated bilateral extrusive lesions withsubstantially diminished mucosal vibration(Figures 1 and 2).Case2A 45 year old gentleman presented withhoarseness since childhood. He noticeda forced quality to his voice with frequentpitch breaks, double tones and vocal fatigue.Videostroboscopic examination of the larynxdemonstrated small gaps remaining anteriorand posterior to the lesion during maximumglottal closure (Figure 3). There was nomucosal wave observed on the lesion.Figure 3Paul LAMFigure 1The correct answers to the last CPD quizwere:Q 1. What is the diagnosis?(B) Superior herniation of the thymusQ 2. If the diagnosis were laryngocoele, what wouldbe the preferred imagining modality?(A) CT scanQ 3. Patients with Phlebectasia can be confirmedwith which imaging technique?(A) Doppler USFigure 2Q 4. Which pharyngeal pouch does the Thymusoriginate embryologically?(C) 3rd35

Case11) What is the most likely diagnosis?a) Sulcus vocalisb) Nodulesc) Papillomatosisd) Epithelial hyperplasiae) Polypoid corditis2) The following treatment modalities may beused for this disease EXCEPTa) carbon dioxide laserb) pulsed dye laserc) cold steel instrument resectiond) microdebridere) botulinum toxin injectionCase23) What is the most likely diagnosis?a) Cystb) Nodulec) Polypd) Reinke’s edemae) Polypoid corditis4) Which of the following is CORRECTconcerning the current problem?a) The pathology is usually of viral origin.b) It is frequently bilateral.c) The chance of aspiration duringswallowing is 15%.d) It usually resolves with adequatehydration and speech therapy.e) The pathology may be composed of anepithelial rest.CPDQuiz June 2007Name:Contact:Your Email:Date:Please reture the answers to the College by fax at 2904 5035 before 30 July 2006. Answers with scores over 75%will be awarded one CPD point. The correct answers will be published in the next issue of Senses.36

Time 8-Nov-07(Thursday)MIS Centre9-Nov-07(Friday)SHAW10-Nov-07(Saturday)11-Nov-07(Sunday)Kai Chong Tong SHAWKai Chong Tong SHAW Kai Chong Tong8:008:309:009:15Pre-ConferenceWorkshop:PhonosurgeryRegistrationEndoscopic TransnasalSkull Base SurgeryMIS in General &Implant OtologyKeynote Lecture:In Otologyby Dr John HOUSEWelcome AddressOpening CeremonyJoint College & Society Lecture:The Evolution of Mastoid Surgeryby Prof Andrew van HASSELT9:3010:0010:30Keynote Lecture:Extended Endoscopic SkullBase Surgery: Things youdid not know you could dojust a few years agoby Prof PaoloCASTELNUOVOCoffee breakJoint College & Society Lecture:The Evolution of Surgery for Laryngeal Cancerby Prof William WEICoffee breakEndoscopic ThyroidSurgeryFESS11:0011:3012:0012:30Hands on Workshopon LaryngologyExtraesophageal refluxOtoendoscopyNBI & AFIThe Wilson Wang Professorial Lecture:Principles and results of Transoral LaserMicrosurgical Resection of Cancer of theUpper Aerodigestive Tractby Prof Wolfgang STEINERTransoral LaryngealLaser SurgeryBronchoscopicStentingEndoscopicHead & NeckSurgeryCoffee breakFESS13:0014:00Luncheon & Satellite Symposium:Which Technology does really help:Separating the Wheat from the Taresby Prof Paolo CASTELNUOVOLuncheon & Satellite Symposium:Transoral Laser Surgery for Tongueand Hypopharyngeal Carcinomasby Prof Wolfgang STEINER14:30Phonosurgery SialoendoscopyFree Papersin EnglishFree Papersin Chinese15:00Coffee breakCoffee break15:3017:00PhonosurgerySialoendoscopyFree Papersin EnglishFree Papersin Chinese19:30Faculty DinnerConference Banquet22:00Seminar Rm 1PEC Hall12-Nov-07(Monday)Seminar Rm 2PEC HallLecture:MITechniques inFacial PlasticSurgeryby Prof StephenPARKPost-ConferenceWorkshop:FESS / Skull BasePost-ConferenceWorkshop:MIFacial PlasticSurgeryCoffee breakFESS / Skull BaseMIFacial PlasticSurgeryLuncheonFESS / Skull BaseMIFacial PlasticSurgery

A Lesurely noteCruise on the Nilealternative for the several days guaranteed to openyour eyes. More importantly, you could enjoy sailingon the river, observing the changing landscapesalong the river bank, watching feluccas glide by,or simply enjoy the sun on the deck while the boatbrings you to the next destination.A trip to Egypt would naturally arouse picturesquethoughts of ‘Pyramids’, ‘Pharaohs’ and ‘Treasures’inside the Egyptian museum in Cairo. If you go southalong the river Nile, you would be overwhelmedby stunning temples and tombs of the great kings,Luxor is the place and a ‘Must’ to visit, once thecapital of Egypt during the most glorious period ofthe Pharaonic Era.Nile cruisersThe duration of a Nile cruise ranges from 4 days3 nights to well over a week depending on whereone chooses to embark and disembark. The mostpopular cruise sails between Aswan and Luxorwhich takes 4 to 5 days.Nile CruiserA leisurely cruise on the Nile is my recommendationfor your itinerary in your Egyptian tour. The sightsalong the river Nile, though many, are quite spreadout and if you should decide to go on wheels, youwould probably need to stay in a different hotelevery night. A nice boat on the Nile is a much betterThere are different kinds of boats you can chooseto sail on the Nile. Feluccas are small sailing boatspropelled by the wind (a little precarious for theHong Kong tribe). There may not be room for yourbags even so ladies must do without their cosmeticcases and formal wear. Nights are spent on theboat or the captain might take you camping onone of the islands along the Nile. This is the mosteconomical way to sail the river. Most travellers,including myself, would choose to stay in one ofthe many Nile cruisers. These boats usually have3 to 4 levels and a sundeck with a pool. Apartfrom the usual restaurant, bar, gymnasium, beautyshop, some boats also have a ‘Casino’. The price40

ange for traveling on a Nile cruiser varies greatlywith the level of luxury opted for. The price usuallyincludes full board meals (without drinks) and all theentrance fees to the monuments together with anEgyptologist. One may choose to sail on a cruiserwithout sightseeing. If money is not a concern, youmay choose to sail on one of the Dahabeeyahs.These are refurbished boats that the ancientEgyptians used to sail on the Nile. They are alltastefully decorated, usually with an antique feel.You have to book the entire boat though, which is fitfor honeymooners, an extended family or a groupof friends. The itinerary of the trip, as well as thefood and wine, and any other service is individuallycatered for.Agatha Christie’s ‘Death on the Nile’ movie withPeter Ustinov, Angela Lansbury, David Niven andso many other top actors and actresses. Dining inher 1902 restaurant is an exquisite experience. Themesmeric ambience and the quality of food andservice are well worth the price.Abu Simbel templefeluccas on the NileWaiting for rejuvenationWe stayed in Aswan for 2 days before we boardedour Nile cruiser. This allowed us some time tovisit the magnificent Abu Simbel temple, whichhas been one of Egypt’s logotypes. I also neededto see the Old Cataract Hotel, which featured inWe boarded the Nile cruiser at noon. We were mostsatisfied with the boat we chose. Our room wasvery spacious with big windows. It was equippedwith two bathrooms. Meals were served in therestaurant upstairs. The quality of food was aboveour expectations. It was top culinary quality, withan impressive range for choice. We were assignedseats at a table with the same five other passengersthroughout the journey, so we had the opportunityto get well acquainted and enjoyed much timesharing our travel experience. After lunch on dayone, we gathered to meet our Egyptologist. He isa knowledgeable, funny and friendly person. He isan archaeologist who had worked for the Egyptiangovernment at the Valley of the Kings and Queensfor many years. We were lucky to have him showingus the historical sights of Egypt. That day he tookus for a felucca ride to the Botanical Gardens for aleisurely stroll in the afternoon. Time became slow,we seemed to have ample of it all of a sudden (notthe Hong Kong way) and we managed to go back tothe cruiser for afternoon tea and then a ‘nap!’. Wethen enjoyed dinner on board, refreshed. Everything41

seemed more colorful and all earthly mattersbecame non-issues.Temple of Horus at EdfuThe Nile cruiserOn day two, we went to the Granite Quarries afterbreakfast. We saw the unfinished obelisk, whichwas unfortunately cracked during harvest so theyhad to abandon it. I was amazed how the ancientEgyptians could harvest and polish such hugepieces of rock with primitive instruments, not tomention how they transferred and erected it on thechosen sites. We then visited the Philae temple byboat. Philae temple was dedicated to the Egyptiangoddess Isis. This massive temple was partiallysubmerged in water when the Aswan dam wasconstructed in 1902. Rescue of the temple wasorganized by the UNESCO in 1972. The templewas disassembled, stone by stone, and moved tothe nearby Agilkia Island where it was reconstructed.We returned to our cruiser for lunch while it sailed toKom Ombo.Temple of the Sobek and Horoeris at Kom OmboThe dual temple of Sobek and Horoeris at KomOmbo was stunning. This temple was dedicated tothe two Gods with its unusual architecture of everystructure duplicated and positioned symmetricallyalong the main axis. Apart from the reliefs of ancientEgyptian Gods on the wall of the temple, we sawinteresting pictures and items in this temple includingPhilae templebeautifully decorated pillars in the temple of Khnum at Esna42

the ancient Egyptian calendar, a set of surgicalinstruments, childbirth and breastfeeding. After thetour we returned to our cruiser and while we werehaving tea, it sailed to Edfu, where we spent thenight. We had a Galabiya and costume party atnight, where passengers were encouraged to dresslike an Egyptian (we tried our best). There weregames and entertainment and it was tremendousfun once disinhibited!over the Valley of the Kings and Queens at Luxor.We gave it a miss for we didn’t really want to get upbefore sunrise for height!Luxor temple with its obelisk in the evening.Galabiya partyThe itinerary for the remaining few days of the cruisewas similarly sensational. We went to one site ofinterest in the morning after breakfast, and anotherone after lunch. In between we had ample timeto relax on the sundeck, or in our own room. Wecould also choose to leave the cruiser for a walk intown. The crew could arrange hot air balloon ridessundeckLuxor templeThere were so many historical sights at Luxor thatthe cruise sightseeing itinerary could only take us tofive. We stayed behind in Luxor after disembarkingto wander on our own to see the rest. While wewere missing the leisurely ‘lazy’ days on the cruiser,it was time to fly over to the Red Sea resort townSharm el-Sheikh for a few days of sun and sea, aperfect finale to the Egyptian holiday. It was then,before we knew it, time to conclude our journey, onewhich had positively captured our heart and souland I am sure yours too if your travel plans shouldtake you on river Nile.Wendy KWAN43