Intraoperative Neuromonitoring for Thyroid Surgery: The Proven Benefits and Limitations

No abstract available.

Clinical Outcomes of a 14-Day In-Hospital Stay Program in Patients Undergoing Head and Neck Cancer Surgery With Free Flap Reconstruction Under the National Health Insurance System

OBJECTIVES: Length of in-hospital stay (LOS) is often regarded as a surrogate marker of efficiency in medical care. A shorter stay can redistribute medical resources to more patients if patient outcomes would not be worsened. However, the adequate LOS remains largely understudied for a complex head and neck cancer (HNC) surgery and free flap reconstruction. METHODS: Active management of LOS (14-day LOS program) included detailed preoperative surgical planning, intensive wound care, postoperative early ambulation and positive psychological encouragement. It was applied to 43 patients undergoing HNC surgery and free flap reconstruction. Outcomes such as noninferior oncological results, rates of timely adjuvant treatments and complications were compared with those of 125 patients without active management of LOS. In addition, the medical costs of shortened LOS were compared with those of the control group. Cases undergoing HNC surgery as a salvage treatment were excluded from both groups for analyses. RESULTS: Active management of LOS resulted in less in-hospital period compared to the control group (15.0 vs. 21.0 days, P=0.001), and reduced medical costs significantly. Incidence of postoperative complications was comparable between the two groups. Oncological outcomes did not differ significantly according to LOS. In all patients in both groups, initial high T status (T3–4) and occurrence of postoperative complications were independent risk factors for long LOS (>30 days). CONCLUSION: In patients undergoing HNC surgery with free flap reconstruction as an initial treatment, a 14-day LOS could be safe in terms of comparable oncological outcomes and postoperative complications. To achieve this goal safely, careful management for T3–4 tumors and prevention of postoperative complications seem to be necessary.

Metastatic Lymph Node Ratio of Central Neck Compartment Has Predictive Values for Locoregional Recurrence in Papillary Thyroid Microcarcinoma

OBJECTIVES: This study aimed to evaluate the significance of metastatic lymph node ratio (the ratio between the metastatic lymph node and the harvested lymph nodes; MLNR) in the central neck for the prediction of locoregional recurrence in patients with papillary thyroid microcarcinoma. METHODS: After reviewing medical records of papillary thyroid microcarcinoma patients who received total thyroidectomy with central neck node dissection, 573 consecutive adult patients were enrolled in this study, with a follow-up period of more than 36 months. Regarding the risk of recurrence, multivariate analyses were performed with the following variables; sex, age, multiplicity of the primary tumor, presence of pathological extrathyroidal extension, the level of postoperative stimulated serum thyroglobulin, the number of harvested lymph nodes, the number of lymph node metastasis and MLNR. RESULTS: The MLNR showed a predictive significance for the locoregional recurrence (P<0.05). Most recurrences were occurred in the lateral neck (n=12, 80%) with a median interval of 20 months. The lowest cutoff value of the MLNR for a meaningful separation of disease recurrence was 0.44 (hazard ratio, 8.86; 95% confidence interval, 1.49 to 52.58; P=0.001). CONCLUSION: When the MLNR is higher than 0.44, there is an increased risk of locoregional recurrence mostly in the lateral neck. Therefore, MLNR of the central neck in a permanent or frozen biopsy may be helpful in decision making in the extent of thyroidectomy and/or the need for contralateral central neck lymph nodes dissection.

A Case of Early Developed Labyrinthine Fistula after Canal Wall Down Mastoidectomy / 대한평형의학회지

Labyrinthine fistula refers to a condition caused by an abnormal connection between the inner ear and surrounding structures. Most cases of that occur as a result of a complication brought about by cholesteatoma. It may also be generated by long repeated infections of a mastoid cavity that has been exposed to the outside after canal wall down mastoidectomy (CWDM). The infection is usually repeated for several years or decades after surgery. Therefore, labyrinthine fistula after CWDM is known as a late complication. In this case, labyrinthine fistula occurred in two months after surgery due to postoperative infection. Although cholesteatoma was removed after CWDM and the horizontal semicircular canal (HSCC) was not damaged during the operation, this labyrinthine fistula was thought to develop very early after surgery. Two months after surgery, the patient complained of dizziness, we identified the opened bony labyrinth and damaged endosteum of the HSCC in the patient.

The Relationship between Snoring Noise and Hearing Impairment in Snorers and Their Spouses / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Snoring is a condition that affects a large percentage of population and is associated with various medical and social complications. However, there are only few published reports investigating the effects of chronic snoring exposure on hearing. In the present study, we examined whether there is an association between chronic snoring noise exposure and noise induced hearing impairment not only in snorers but also in their spouses. Subjects and MethodZZSixty snorers and 27 spouses under the age of 55 were recruited. All participants had more than 5 years of exposure to snoring. Questionnaire for snoring and pure tone audiometry were conducted. Subjects were classified into normal hearing group and hearing impairment group. SUBJECTS AND METHOD: Sixty snorers and 27 spouses under the age of 55 were recruited. All participants had more than 5 years of exposure to snoring. Questionnaire for snoring and pure tone audiometry were conducted. Subjects were classified into normal hearing group and hearing impairment group. RESULTS: Forty percent of snorers and 25.9% of spouses had hearing impairment. The snorers with hearing impairment had longer duration of snoring than the snorers with normal hearing. However, there were no statistical differences in loudness of snoring between the two groups. In the spouse group, there were statistical differences in loudness of exposed snoring and in duration of snoring exposure between the hearing impairment group and the normal hearing group. CONCLUSION: The result of this study indicated that chronic exposure to snoring noise may be associated with hearing impairment in snorers and their spouses. But in the snorers, further studies are required to identify the factors other than snoring noise associated with hearing impairment.

Dietary Supplements and Postoperative Bleeding

There is a wide variety of dietary supplements on the market that are taken by patients of all walks of life. Unfortunately their use is self-prescribed and patients rarely view them as medication reveal their use to hospital staff. Garlic has been reported to inhibit platelet aggregation and may interact with anticoagulants and antiplatelet agents. Other alternative supplements have also been associated with potential increased bleeding, including ginkgo biloba, ginger, ginseng, and omega-3 fatty acid. It is essential for surgeons to be apprised of all substances ingested by patients, so they can identify potential adverse effects and drug interactions.

Transition from Canalolithiasis to Cupulolithiasis by the Head-Bending Posture and Canalith Repositioning by Using the Side-Lying Position in Benign Paroxysmal Positional Vertigo of Horizontal Semicircular Canal / 대한평형의학회지

Benign paroxysmal positional vertigo is the most common disease of the peripheral vestibular disorder. A 51-year-old man showed geotropic horizontal nystagmus in the head roll test. After head-bending posture, the nystagmus of the patient was changed to apogeotropic horizontal nystagmus in the head roll test. We concluded that transition of canalolithiasis into cupulolithiasis happened during head-bending posture. The cupulolithiasis was returned to canalolithiasis by using side-lying position with the affected ear downward for approximately 45 minutes.

Preoperative Measurement of Submandibular Gland Stone Size / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The choice of optimal treatment methods among various gland preserving procedures including transoral surgery, sialendoscopy and extracorporeal lithotripsy for submandibular stones is mainly determined by the size of the stone. We tried to assess the accuracy of ultrasonography (USG) and computerized tomography (CT) for the preoperative estimation of submandibular gland stone size. SUBJECTS AND METHOD: We retrospectively reviewed the medical records of 251 patients who were treated for submandibular stones from January 2008 to December 2014. Eighty patients who checked both preoperative USG and CT were included. Preoperative USG and CT measurements of the submandibular stones were compared to postoperative measurements of removed stones. Effects of stone location and presence of acute infection on preoperative measurements were also assessed. RESULTS: The mean submandibular gland stone size was 6.60+/-3.8 mm by USG, 7.23+/-4.0 mm by neck CT and 7.89+/-4.7 mm by the postoperative measurement. USG and CT showed good correlation with the postoperative measurement (correlation coefficient 0.912 and 0.940, respectively). The location of stone and presence of combined infection showed no significant impact on the accuracy of USG and CT measurement. CONCLUSION: USG and neck CT showed high accuracy for predicting submandibular gland stone size. However, it should be taken into consideration that the stone size could be greater than that shown by preoperative measurement.

A Clinical Analysis of Patients Who Visited Emergency Department due to Chemical Incident Occurred at Industrial Place: A Retrospective Study

PURPOSE: The purpose of this study is to understand what kinds of chemical substances have been used annually and to investigate incidents that occurred due to chemical hazard release and to analyze statistically clinically chemical injury patients who visited one regional emergency medical center in Gumi city with documented references review. METHODS: Annual chemical waste emission quantity (Kg/Year) (Cwep) was reproduced using national web site data governed by the Ministry of Environment and 5 years (from 1 .Jan. 2010 to 31. Dec. 2014) of medical records of chemical injury patients who visited our emergency department were reviewed retrospectively. By applying exclusion criteria, 446 patients of 460 patients were selected. RESULTS: Dichloromethane, Toluene, Trichloroethylene, and Xylene were always included within Top 5 of Cweq. Six cases of chemical incidents were reported and in 3 of 6 cases involving Hydrogen fluoride were included during the study period. Male gender and twenties were the most prevalent group. Injury evoking chemicals were Hydrogen fluoride, unknown, complex chemicals (over 2 substances) in sequence. The most frequent site of wounds and injuries was the respiratory tract. Gas among status, intoxication among diagnosis, and discharge among disposition was most numerous in each group. CONCLUSION: There have been no uniform clinical protocols for chemical wounds and injuries due to various kinds of chemicophysical properties and ignorance of antidotes. Therefore conduct of a multicenter cohort study and experiments for ruling out chemicals according to chemicophysical priority as well as development of antidotes and clinical protocols for chemical injury patients is needed.

Comparison of Two Sedation Protocols for Postoperative Intensive Care Unit Care after Head and Neck Reconstructive Surgery: Midazolam/Morphine versus Remifentanil Sedation / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: In head and neck reconstructive surgery, the stability of vital signs is important for patient recovery and flap outcome. We aimed to determine the better sedation protocol by comparing two protocols, namaely, midazolam/morphine (MM)-based and remifentanil (RF)-based sedation protocols, in the immediate postoperative settings of head and neck reconstructive surgery. SUBJECTS AND METHOD: We retrospectively reviewed the medical data of patients who underwent reconstructive surgery after the ablation of head and neck cancer involving MM sedation (n=34) or RF sedation (n=28). Parameters related to vital signs, flap outcomes, occurrence of delirium, length of stay and nursing burden were compared between the groups. RESULTS: The length of stay at the intensive care unit and flap outcomes were similar in the two groups. However, blood pressure as measured by frequency of variation was more stable in the RF group than in the MM group. In addition, the number of medical calls from the attending nurse due to the fluctuation of vital signs was less in the RF group than in the MM group. CONCLUSION: RF-based sedation for the postoperative intensive care unit care after head and neck reconstructive surgery is more effective in cases where vital signs are less stable. This type of sedation may decrease the nursing burden for these patients.

Evaluation of Lymph Nodes in Patients with Concurrent Papillary Thyroid Carcinoma and Cervical Tuberculous Lymphadenitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To determine the diagnostic clues to differentiate tuberculous lymph node infection from nodal metastasis in patients with both papillary thyroid carcinoma and cervical tuberculous lymphadenitis. SUBJECTS AND METHOD: We retrospectively reviewed 11 patients suffering concurrently from papillary thyroid carcinomas with cervical tuberculous lymphadenitis. Nine of the 11 patients underwent preoperative neck ultrasonography (US) and seven CT scans. Using the surgical pathology as the reference standards, the results of the preoperative diagnostic tools were re-evaluated according to lymph node level-based analysis. US and CT features were also compared between metastatic nodes and tuberculous lymphadenitis. RESULTS: Preoperative CT could localize the involved lymph node levels and differentiate tuberculous infection from metastasis of thyroid carcinoma in only two of seven patients. The site of the involved lymph nodes, the presence of pulmonary tuberculosis, and the tumor volume of the thyroid carcinoma were the clues to diagnose the lymph node status. However, in five of seven cases, CT could not differentiate tuberculosis from metastasis in the lymph nodes. The morphological characteristics of lymph nodes seen on CT and US did not differ between tuberculous infection and metastasis of papillary thyroid carcinomas. CONCLUSION: Pre-operative CT or US does not provide differential information about lymph node status between tuberculous infection and metastasis in patients with concurrent papillary thyroid carcinomas and cervical tuberculous lymphadenitis. Rather, clinical characteristics such as the site of the involved lymph nodes, the primary tumor burden, and the associated clinical features can help the physician differentiate between them.

The Prognostic Role of p16 Expression in Tonsil Cancer Treated by Either Surgery or Radiation

OBJECTIVES: Although human papillomavirus (HPV) infection is considered as a favorable prognostic factor in oropharyngeal cancer, the prognosis of HPV-associated tonsil cancer has rarely been studied especially when surgery was the main treatment. In this study, the authors investigated the effect of p16 over-expression (HPV infection) on tonsil cancer prognosis according to the type of treatment, HPV presence by PCR, and expression of p53 and epidermal growth factor receptor (EGFR) by immunohistochemistry (IHC). METHODS: Medical records of 33 tonsil cancer patients were reviewed. Using formalin-fixed and paraffin-embedded tumor specimens, PCR-based genotyping of HPV and IHC of p16, p53 and EGFR were performed. The effects of HPV presence and the expression of IHC markers were analyzed on the recurrence-free survival. Five-year disease-free survival (DFS) rates were evaluated according to p16 expression status. RESULTS: An over-expression of p16 was observed in 27 (81.9%) out of 33 cases. Surgery-based treatment was provided for 21 (63.6%) patients. There was no association between p16 immunoreactivity and HPV presence, nor with p53 and EGFR expression. Regardless of main treatment modalities, five-year DFS did not differ by p16 expression status (P=0.051). However, over-expression of p16 was associated with a lower recurrence in multivariable analyses (P=0.046). CONCLUSION: Regardless of main treatment modalities, an over-expression of p16 (HPV infection) is associated with a lower recurrence in tonsil cancers. However it is not associated with simple HPV presence or p53 and EGFR over-expression.

Comparison of the Efficacy of Systemic and Combined Highly Frequent Intratympanic Steroid Treatment on Sudden Sensorineural Hearing Loss

BACKGROUND AND OBJECTIVES: Corticosteroids have been used for therapeutic management of sudden sensorineural hearing loss (SSNHL). Because of the complications associated with systemic steroid therapy and low levels of steroid in the inner ear after systemic administration, intratympanic steroid injection (ITSI) is currently used. The purpose of this study was to compare the efficacy of systemic steroid therapy with systemic combined high frequency ITSI therapy. SUBJECTS AND METHODS: Forty-six SSNHL patients were divided into the only systemic dexamethasone therapy group (systemic steroid IV group, 27 patients) and the systemic with frequent intratympanic dexamethasone injection group (combined ITSI group, 19 patients). In the systemic steroid IV group, dexamethasone was administered intravenously for 5 days followed by oral tapered doses for 10 days. In the combined ITSI group, intratympanic dexamethasone was administered 5 times per day for 5 consecutive days in addition to intravenous administration of dexamethasone. Hearing was assessed both before therapy and at 15 days, 4 weeks, and 8 weeks after the initiation of therapy. RESULTS: The recovery rate and hearing gain were 74% (20 out of 27 patients) and 33 dB mean improvement in the systemic steroid IV group and 73.6% (14 out of 19 patients) and 41.5 dB mean improvement in the combined ITSI group. There was no statistically significant difference in hearing gain and the recovery rate between the two groups. CONCLUSIONS: The therapeutic effect of a combination of highly frequently administered intratympanic dexamethasone and systemic steroid therapy was not superior to only systemic steroid injection therapy.

The Effect of Tonsil Size on the Obstructive Sleep Apnea in Adults

BACKGROUND AND OBJECTIVES: Obstructive sleep apnea (OSA) is a complex disease with multifactorial etiologic factors. The purpose of this study was to compare the tonsil size and weight along with polysomnographic and cephalometric findings and subjective symptoms of adult OSA. MATERIALS AND METHODS: Tonsil size and weight were measured. Preoperative polysomnographic (PSG) results (AHI, SaO2, sleep efficiency, arousal index), cephalometric findings, objective symptoms [Pittsburgh sleep quality index (PSQI), Stanford sleepiness scale (SSS), and Epworth sleepiness scale (ESS)] were compared according to tonsil size and weight using Spearman rank correlation coefficients. RESULT: Thirty-four adult patients were included. Tonsil size was inversely correlated with minimal oxygen saturation (gamma=-0.394, p=0.034), and tonsil weight was inversely correlated with minimal oxygen saturation (gamma=-0.412, p=0.040) and sleep efficiency (gamma=-0.400, p=0.047) in PSG. In terms of anatomic correlation, tonsil size was correlated with cross sectional area of hypopharynx (gamma=0.377, p=0.048), while tonsil weight correlated with cross sectional area of the tongue (gamma=0.459, p=0.014) and cross sectional area of the soft palate (gamma=0.419, p=0.026). However, tonsil size and weight were not correlated with subjective symptoms of the patients. CONCLUSION: With limited evidence, adult tonsil size and weight may influence the severity of OSA.

Taste Thresholds of Phenylthiocarbamide and 6-n-Propylthiouracil and their Correlation with TAS2R38 Genotype / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Phenylthiocarbamide (PTC) and its chemically related compound,6-n-propylthiouracil (PROP), both produce a taste that is extremely bitter to some subjects (tasters) but tasteless or only slightly bitter to others (non-tasters). Earlier studies had used PTC, but most investigators have switched to PROP because of its several advantages. Recently, three single nucleotide polymorphisms in the TAS2R38 gene were identified and several studies have demonstrated a strong association between these genes with taster status. The aim of this study was to investigate the relationship between taste thresholds of PTC and PROP and their correlation with the TAS2R38 genotype. SUBJECTS AND METHOD: Seventy-five healthy normal volunteers were included. Taster status was determined using successive solutions of PTC and PROP, which comprised a total of 15 grades. All participants were genotyped for polymorphism of the TAS2R38 gene that affects taste sensitivity to PTC and PROP. RESULTS: PTC taste thresholds showed 96% correlation with the taste thresholds for PROP. Non-tasters defined by the PTC threshold test were the exactly the same with those identified as AVI (alanine, valine, isoleucine) homozygous, but taster status determined by the PROP threshold test showed 96% correlation with the genotypes. CONCLUSION: The PTC threshold test was more reliable for determining taste blindness than the PROP threshold test.

Ultrasonographic Features of the Parotid Gland Neoplasms / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Ultrasonography represents the initial imaging modality of choice for the assessment of the parotid gland tumors. The aim of this study is to evaluate the role of ultrasonography in differential diagnosis of the parotid gland tumors. SUBJECTS AND METHOD: Ultrasonography of the 49 patients with parotid gland tumors were retrospectively reviewed. Histology of all cases was confirmed after parotidectomy. The ultrasonographic features of the most common two histologies, namely, pleomorphic adenoma and Warthin's tumor, were compared. RESULTS: Pleomorphic adenomas were usually solid and they showed lobulation and an exophytic growth. Warthin's tumors usually contained a cystic component, and were usually oval without lobulation and confined to the parenchyma. One of two malignancies showed well-defined margins and five benign tumors showed ill-defined margins. CONCLUSION: The ultrasonographic features should be cautiously used to discriminate among the various histologies of parotid gland tumors.

Clinical Findings and Treatment of Partially Lateralized Tympanic Membrane / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Partially lateralized tympanic membrane (TM) is a complication of tympanoplasty or healing process. We could detect them by careful examination and treat easily by re-operation. SUBJECTS AND METHOD: We experienced seven patients of partially lateralized TM. We analyzed their clinical symptoms, physical findings, operative findings and pre- and post-audiograms. RESULTS: Six patients had re-operation and one patient had complication within one year after type I tympanoplasty. They had hearing loss, otorrhea, and tinnitus. In particular, one patient had earfullness, autophonia like patent Eustachian tube because of lateralized TM. One difficult case of anterior perforation of blunted TM was operated 3 times. We could improve the hearing in all of six patients after surgery. CONCLUSION: Partially lateralized TM is primarily a complication of otologic surgery. It causes still hearing loss, otorrhea, earfullness and tinnitus after primary surgery, which can be repaired by re-operation. In case of perforation on anterior blunted TM, however, it may not be repaired by general procedure and need approach with caution. For prevention, otologic surgeons should have thorough knowledge of surgical principles and carefully watch not to miss it. It is not a very rare complication.

A Study on Air Pollution and Thermal Factors in Underground Shopping Center of Pusan Area / 예방의학회지

For the purpose of preparing the fundamental data on air pollution in underground shopping center and also contributing to the health improvement of resident, the authors measured the level of SO2, NO2, TSP, CO, CO2 and also some related factors as air temperature, air movement, relative humidity and mean radiation temperature at inside and outside of underground shopping center in Pusan from January to February and from July to August 1994. The results were as follows: 1. The mean concentration of CO within the underground shopping center was 3.1+/-1.3ppm in winter and 2.1+/-0.9 ppm in summer. There was a negative correlation (p<0.01) between inner CO concentration and temperature in summer and no correlation between inner CO concentration and outer CO concentration in underground shopping center 2. The mean concentration of C02 within the underground shopping center was 876+/-353 ppm in winter and 757+/-125 ppm in summer. There was a negative correlation (P<0.01) between inner CO2 concentration and air movement in summer and positive correlation (p<0.05) between inner CO2 oncentration and outer CO2 concentration in underground shopping center. 3. The mean concentration SO2 within a underground shopping center was 0.036+/-0.019ppm in winter and 0.040+/-0.013ppm in summer. There was a positive correlation(p<0.01) between inner SO2 concentration and positive correlation between inner SO2 concentration and outer SO2 concentration in summer and winter in Underground shopping center. 4. The mean concentration of NO2 within a underground shopping center was 0.052+/-0.038ppm in winter and 0.042+/-0.016ppm in summer. There was a no correlation between inner NO2 concentration and thermal factors in summer and winter and low correlation between inner NO2 concentration in underground shopping center. 5. The mean concentration of TSP within a underground shopping center was 430+/-214 microgram/m3 in winter, 366+/-73 microgram/m3 in summer, and very in excess of the atmospheric environmental quality standards of Korea(150 microgram/m3). There was low correlation between inner TSP concentration and temperature in summer and high correlation between inner TSP concentration and outer TSP concentration in underground shopping center.