Iatrogenic Development of Cerebrospinal Fluid Leakage in Diagnosing Spontaneous Intracranial Hypotension / 가정의학회지

A 34-year-old woman came to the emergency room complaining of a severe orthostatic headache. Results of a cerebrospinal fluid tap and brain computed tomography were normal. Based on her history and symptoms, she was found to have spontaneous intracranial hypotension. She was hospitalized and her symptoms improved with conservative treatment. On the next day, her headache suddenly worsened. Cisternography was performed to confirm the diagnosis and determine the spinal level of her cerebrospinal fluid leak. It revealed multiple cerebrospinal fluid leaks in the lumbar and upper thoracic regions. It was strongly believed that she had an iatrogenic cerebrospinal fluid leak in the lumbar region. An epidural blood patch was performed level by level on the lumbar and upper thoracic regions. Her symptoms resolved after the epidural blood patch and she was later discharged without any complications. In this case, an iatrogenic cerebrospinal fluid leak was caused by a dural puncture made while diagnosing spontaneous intracranial hypotension, which is always a risk and hampers the patient's progress. Therefore, in cases of spontaneous intracranial hypotension, an effort to minimize dural punctures is needed and a non-invasive test such as magnetic resonance imaging should be considered first.

Unilateral sudden sensorineural hearing loss after combined spinal-epidural anesthesia for emergency cesarean section: A case report

A 30-year-old primigravida with gestational age of 25 weeks and 4 days was admitted for emergency cesarean section. She was diagnosed as pre-eclampsia with fetal distress. We anesthetized the patient through the combined spinal-epidural anesthetic technique, and there was no specific event throughout the surgical procedures and in post anesthetic care unit. Subsequently, she complained of unilateral hearing difficulty in the ward and an otolaryngology consultation was obtained. She was diagnosed with left sudden sensorineural hearing loss in full frequency range after an acoustic examination. She received intravenous and local steroid treatments for 4 weeks. She showed 32 dB on pure tone audiometry after 5 months. However, we could not continue follow-up testing on the patient because she stopped visiting the hospital since the last examination. We reported a case of uncommon unilateral sudden sensorineural hearing loss after a combined spinal-epidural anesthesia for emergency cesarean section.

A comparison of oxycodone and fentanyl in the management of early postoperative pain and for patient-controlled analgesia after total abdominal hysterectomy

BACKGROUND: Although oxycodone has been known to be superior to other opioids in postoperative care, few studies have compared its analgesic potency with that of fentanyl. We therefore examined these two drugs in terms of their dose requirements, effects on pain intensity, time needed for relief of pain, and side effects after surgery. METHODS: We enrolled 56 healthy women scheduled for total abdominal hysterectomy and randomly allocated them to either oxycodone or fentanyl. The opioids were administered to the two groups 10 minutes before the end of the operation. In the post-anesthesia care unit (PACU) after surgery, a visual analog scale (VAS) was used to assess the patients' pain every 10 minutes Whenever pain control was required, a bolus of the same dose of the respective drugs was repeated at 10-minute intervals. Patient-controlled analgesia (PCA) was used to manage postoperative pain. After the patient arrived on the ward, pain scores were recorded at once and then 1, 2, 3, and 24 hours thereafter. RESULTS: During the hour spent in the PACU, fewer patients in the oxycodone group required the opioid, and the time needed to achieve pain relief was shorter with oxycodone than with fentanyl. Moreover, postoperative VAS levels were significantly lower in the oxycodone group both in the PACU and on the ward (over a 24-hours period). There were no significant differences in side effects between the patients given oxycodone and those given fentanyl. CONCLUSIONS: Oxycodone was more effective than fentanyl when administered on the basis of the recommended dose ratio (1 : 100). Although further evaluation is needed to investigate the optimal dose ratio, we would recommend a higher conversion factor (1 : 62).

Difficult intubation using intubating laryngeal mask airway in conjunction with a fiber optic bronchoscope

When anesthesiologists encounter conditions in which intubation is not possible using a conventional direct laryngoscope, they can consider using other available techniques and devices such as fiber optic bronchoscope (FOB)-guided intubation, a laryngeal mask airway (LMA), intubating LMA (ILMA), a light wand, and the Combitube. FOB-guided intubation is frequently utilized in predicted difficult airway cases and is generally performed when the patient is awake to enable easier access to the trachea. An LMA can be introduced to ventilate the patient with relative ease, while an ILMA can be used for definite endotracheal intubation. However, occasionally, an endotracheal tube (ETT) cannot pass through the larynx, despite successful introduction of a FOB into the trachea and placement of an ILMA by the anesthesiologist. Therefore, we initially introduced an ILMA for emergent ventilation, followed by successful insertion of an ETT under FOB guidance. In this report, we describe three cases of difficult intubation using a FOB and ILMA combination approach.

Difficult intubation using intubating laryngeal mask airway in conjunction with a fiber optic bronchoscope

When anesthesiologists encounter conditions in which intubation is not possible using a conventional direct laryngoscope, they can consider using other available techniques and devices such as fiber optic bronchoscope (FOB)-guided intubation, a laryngeal mask airway (LMA), intubating LMA (ILMA), a light wand, and the Combitube. FOB-guided intubation is frequently utilized in predicted difficult airway cases and is generally performed when the patient is awake to enable easier access to the trachea. An LMA can be introduced to ventilate the patient with relative ease, while an ILMA can be used for definite endotracheal intubation. However, occasionally, an endotracheal tube (ETT) cannot pass through the larynx, despite successful introduction of a FOB into the trachea and placement of an ILMA by the anesthesiologist. Therefore, we initially introduced an ILMA for emergent ventilation, followed by successful insertion of an ETT under FOB guidance. In this report, we describe three cases of difficult intubation using a FOB and ILMA combination approach.

Six Cases of Nasal Cavity and Nasopharyngeal Tuberculosis / 대한이비인후과학회지

Tuberculosis of the nasal cavity and nasopharynx is extremely rare. The diagnosis is frequently delayed because of unfamiliarity with the disease. It is difficult to make an accurate diagnosis of tuberculosis of the nasal cavity and nasopharynx on imaging findings alone; a biopsy is required to confirm the diagnosis and to differentiate it from malignancy and the other conditions. The authors have experienced 6 cases of tuberculosis of the nasal cavity and nasopharyx. We report them with review of literatures.

Guillain-Barre Syndrome Presenting as Bilateral Vocal Cord Paralysis / 대한이비인후과학회지

Guillain-Barre syndrome (GBS) presenting as bilateral vocal cord paralysis is extremely rare. We report an unusual case of GBS in which the patient manifested hoarseness resulting from bilateral vocal cord paralysis. In conclusion, GBS needs to be considered as possible causes of new onset bilateral vocal cord paralysis. We emphasize that early recognition of atypical presentations of GBS warrants further evaluation and appropriate management.

A Case of Inverted Papilloma Originating from Posterior Nasal Septum

Inverted papilloma is an uncommon benign nasal tumor which usually occurs on the lateral nasal wall. An inverted papilloma originating from the medial nasal cavity, especially the nasal septum, is considered very rare. A 47-year-old male was referred with a 1-month history of snoring. On endoscopic examination, a nasal mass was observed in the left posterior septum. The mass filled the left nasal cavity and extended choanae and nasopharynx. The histopathologic examination of the nasal mass showed inverted papilloma, which was completely removed by endoscopic surgery. Herein, the authors report a case of inverted papilloma originating from the posterior nasal septum as well as a review of literature.

Comparative Study of Sensation with or without Preservation of Great Auricular Nerve during Parotidectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Whether to sacrifice the posterior branch of great auricular nerve (GAN) during parotidectomy is disputatious. This study was to provide a guideline for decision-making. SUBJECTS AND METHOD: Thirty-two patients who underwent parotidectomy due to parotid mass were randomized into two groups. Three patients who underwent further treatment were excluded. Fourteen patients underwent classic parotidectomy by sacrificing GAN whereas 15 patients underwent surgery that preserved the nerve. A two-point discrimination test, sensation of light touch, sharp instrument, blunt instrument and temperature were evaluated preoperatively, and at 7 days, 1, 3, 6, 12 months and 45 months, postoperatively. Patients' preference for the operation time to preserve the nerve was also evaluated. RESULTS: The mean preservation time was 156 seconds. There was no difference in touch sensation, preoperatively, between the two groups. The two-point discrimination test of the infra-auricular area showed significant differences at 1 week postoperatively (p<0.05). The two-point discrimination test of lobule showed significant differences at 1 month (p<0.05), but these differences disappeared at 1 and 3 months. All measured data had no statistically significant differences at 3 and 6 months. At one year, light touch sensation of lobule and temperature sensation of infra-auricular area showed significant differences (p<0.05). Differences in temperature were found at 45 months of follow-up. Of the patients, 95% wanted to preserve the nerve. CONCLUSION: The authors suggest that the posterior branch of GAN was preserved according to patients' preference for the sensation of temperature in the infra-auricular area.

Neurilemmoma at Rare Sites: Two Cases Report

Although approximately 13% of neurilemmomas occur in the extracranial head and neck region, those originating in the trachea or at the base of the tongue are rare. We report the CT and MR imaging findings of two cases of neurilemmoma, one arising in the trachea and the other at the base of the tongue.

Drug-induced MR Urography: The effects of Furosemide and Intravenous Saline Injection on MR Urography of Obstructed and Non-obstructed Urinary Tract

PURPOSE: To determine the usefulness of MR urography technique for the evaluation of urinary systems in patients with obstructed urinary tract and normal volunteers with non-obstructed urinary tract after intravenous normal saline and diuretic injection. MATERIALS AND METHODS: Three normal volunteers and 12 patients with urinary tract obstruction [ureteral calculi(n=8), extraurinary mass(n=1), ureteral tumor invasion(n=3)] underwent MR urography using a 1.0T scanner and a 2D non-breath-hold heavily T2-weighted fast spin-echo sequence. These acquisition were postprocessed with a maximum intensity projection (MIP) algorithm. Two acquisitions were performed, the first prior to saline solution infusion following standard MR urography procedures, and the second, within 2-3 minutes of the infusion of 250 ml saline solution followed by 20 mg of Lasix administered intravenously. For this latter, drug-induced MR urography procedures were followed. RESULTS: In healthy volunteers (n=3) and those experiencing partial obstruction (n=4) by a urinary stone, drug-induced MR urography provided better images of the urinary tract than did standard MR urography. In those in whom a urinary stone or tumor had caused complete obstruction (n=8), standard MR urography provided good images, as did drug-induced MR urography. CONCLUSION: In patients with a partially or non-obstructed urinary tract, drug-induced MR urography provided better anatomic and functional details of the kidney and urinary tract than did standard MR urography. In those experiencing complete obstruction of the urinary tract, however, standard or drug-induced MR urography permitted very adequate evaluation of the tract, and drug-induced MR urography was unnecessary.

Colloid Cyst in Pituitary Gland: A Case Report

Colloid cyst is a congenital lesion which is thought to be derived from the primitive neuroepithelium, and is most frequently located in the anterior half of the third ventricle. Colloid cysts rarely occur in the pituitary gland, and we describe a case of pituitary colloid cyst, including the CT, MRI and pathologic findings.

MR Findings of Facial Nerve on Oblique Sagittal MRI Using TMJ Surface Coil: Normal vs Peripheral Facial Nerve Palsy

PURPOSE: To evaluate the findings of normal facial nerve, as seen on oblique sagittal MRI using a TMJ (tem-poromandibular joint) surface coil, and then to evaluate abnormal findings of peripheral facial nerve palsy. MATERIALS AND METHODS: We retrospectively reviewed the MR findings of 20 patients with peripheral facial palsy and 50 normal facial nerves of 36 patients without facial palsy. All underwent oblique sagittal MRI using a TMJ surface coil. We analyzed the course, signal intensity, thickness, location, and degree of enhancement of the facial nerve. According to the angle made by the proximal parotid segment on the axis of the mastoid seg-ment, course was classified as anterior angulation (obtuse and acute, or buckling), straight and posterior angu-lation. RESULTS: Among 50 normal facial nerves, 24 (48%) were straight, and 23 (46%) demonstrated anterior angula-tion; 34 (68%) showed iso signal intensity on T1WI. In the group of patients, course on the affected side was either straight (40%) or showed anterior angulation (55%), and signal intensity in 80% of cases was isointense. These findings were similar to those in the normal group, but in patients with post-traumatic or post-operative facial palsy, buckling, of course, appeared. In 12 of 18 facial palsy cases (66.6%) in which contrast materials were administered, a normal facial nerve of the opposite facial canal showed mild enhancement on more than one segment, but on the affected side the facial nerve showed diffuse enhancement in all 14 patients with acute facial palsy. Eleven of these (79%) showed fair or marked enhancement on more than one segment, and in 12 (86%), mild enhancement of the proximal parotid segment was noted. Four of six chronic facial palsy cases (66.6%) showed atrophy of the facial nerve. CONCLUSION: When oblique sagittal MR images are obtained using a TMJ surface coil, enhancement of the proximal parotid segment of the facial nerve and fair or marked enhancement of at least one segment within the facial canal always suggests pathology of the facial nerve. The use of this modality, together with the coil, is, therefore, an effective complementary technique for the evaluation of a facial nerve.

Helical CT of a Tracheobronchial Phantom: Angle and Optimal Window Affecting Size Measurements of ThreeDimensional Images

PURPOSE: To determine the effect of angle variation, relative to scan plan and optimal window setting, on thesize of three dimensional spiral CT images of a tracheobronchial tree using a phantom. MATERIALS AND METHODS:Spiral CT[collimation(mm)/table speed(mm/sec): 3/3; reconstruction interval:1.5 mm] was performed on atracheobronchial phantom consisting of a box filled with saline solution containing air-filled 5cc syringesoriented at varying angles relative to the scan plan. The diameter of three dimensional images was measured ateach window(minimal threshold value; -1000 HU; maximaml threshold value: from -300 HU to -500 HU; 50 HU interval). RESULTS: The inner diamenter of syringes used for tracheobronchial phantom was 12.55 +/-3.19mm. At all windows,as the angle became more perpendicular, the diameter of three-dimensional images increased, and at all angles, asmaxinal HU increased, measured diameter also increased(p<0.0001). In particular, at a maximal value of -500HU,measured values were closest to control values at all angles. CONCLUSION: Diameter can be measured close tocontrol value from three dimensional spiral CT images at maximal HU of -500 window, regardless of angle.

Plugging the Biopsy Tract in Rabbit Liver: Gelfoam, Fibrin Sealant and NBCA

PURPOSE: To evaluate the effect of plugging the biopsy tract in rabbit liver and the pathologic changes caused by plugging materials. MATERIALS AND METHODS: Thirty-two New Zealand White rabbits were divided into four groups(eight rabbits in each) and compared with one another. They were labeled group A(control), B(gelfoam),C(fibrin sealant) or D(NBCA). The liver was exposed and biopsied with an 18G disposible biopsy gun. The inner Tru-cut needle was withdrawn and plugging was undertaken through the outer cannula of the biopsy gun. Bleeding times of each material were compared. The rabbits were sacrificed and pathologically evaluated for 17 days. RESULTS: Mean bleeding times were 46.7+/-34.5 sec in group A, 42.9+/-54.7 sec in group B, 12.6+/-15.0 sec in group C, and 0 sec in group D. In groups C and D, these results were statistically significant(p<0.01). Pathologically, fibrin sealant was lowest in foreign body reaction and fibrosis. NBCA was effective for the prevention of hemorrhage. CONCLUSION: NBCA and fibrin sealant effectively plug the biopsy tract through the outer cannula of an18 G biopsy gun.

Percutaneous biopsy of malignant hepatic tumor in patients with bleeding tendency: Usefulness of gelfoamplugging up the biopsy track

PURPOSE: To plug the biopsy site in eight patients with coagulopathy who had undergone percutaneous liverbiopsy. To this end, gelfoam cartridge was used as a sealant. MATERIALS AND METHODS: Using an 18G Tru-Cut-typedisposible automated biopsy gun(Soo Ho Medi-tech, Seoul, Korea) and under US guidance, eight patients underwentpercutaneous liver biopsy. After the gun had fired, the biopsy specimen in the inner stylet was retrieved whilethe outer cannula was held in place ; the cannula was then used to plug the biopsy tracks with gelfoam, using twoor three cartridges. If bleeding occurred, this was controlled by the use of more gelfoam cartridges. RESULTS: Diagnostic target tissue was obtained in seven of the eight patients(87.5%). Hepatocellular carcinoma wasdiagnosed in five cases and metastatic cancer in two. Profuse bleeding was observed in one patient(12.5%) andresolved by gelfoam plugging. CONCLUSION: We believe that in patients with coagulopathy who are required toundergo liver biopsy plugging the liver biopsy track with gelfoam cartridge is a simple, safe and useful method.

Intra-arterial Port Implantation for Intraarterial Chemoinfusion

PURPOSE: To evaluate, using various port systems, the technique and complications of intra-arterial portimplantation in visceral (mainly hepatic) arteries for intra-arterial chemoinfusion. MATERIALS AND METHODS: Weretrospectively evaluated 30 cases of intra-arterial port implantation in 29 patients. Angiography was performedin all cases, and insertion of an implantable polyurethane port catheter was followed by angiographic exchangewhich, utilizing a .035" hydrophilic guide wire, targeted the artery. If a change in the direction of flow wasrequired, arterial flow control was performed, using an enbolie coil. In order to insert the subcutaneous portchamber, an incision approximately 4cm long was made at the puncture site and subcutaneous tissue was dissected.The port chamber was inserted into the subcutaneous pocket and fixed with a black-silk tagging suture. When thefemoral artery was punctured, the port chamber was inserted into the supra-or infrainguinal area; when the leftsubclavian artery was used, the port chamber was inserted into the lateral one third of the left clavicle. Theport systems used in the procedure were as follows : 5.8F Port-A-Cath (SIMS, Deltec, U.S.A.)(n=20) ; 5.2F A-Port(Therex, U.S.A.)(N=5); 5F PU-Anthron(Deny, Japan)(n=4) ; 5.2F R-Port(Therex, U.S.A.)(n=1). The subcutaneouschambers were inserted into the infrainguinal (n=22), suprainguinal (n=6) or subclavian area(n=2). RESULTS: Theprocedure was technically successful in all 30 cases. Port catheter tips were located in the hepatic arteryproper(n=11), the right hepatic(n=9), gastroduodenal (n=6), common hepatic (n=2), inferior mesenteric (n=1) andinternal iliac artery(n=1). In 12 cases, flow was controlled using embolic coils. Follow-up study was performed in23 cases, with a mean follow up period of 55.8 (11-161) days. Complications were noted in four cases ; two wereprocedure related and two were catheter related. CONCLUSION: Intra-arterial port implantation is a safe procedureand can be performed easily by skilled radiologists; long-term observation is, however, still needed.

Inspiratory and Expiratory HRCT Findings in Healthy Smokers' Lung

PURPOSE: To evaluate the lung changes in healthy smokers, as seen on inspiratory and expiratoryhigh-resolution computed tomography (HRCT). MATERIAL AND METHODS: Twenty-seven healthy smokers (light smokers,below 20 pack-years, n=16; heavy smokers, above 20 pack-years, n=11) and 25 nonsmokers underwent inspiratory andexpiratory HRCT. All healthy smokers had normal pulmonary function and chest radiography. Parenchymal andsubpleural micronodules, ground-glass attenuation, centrilobular and paraseptal emphysema, bronchial wallthickening, bronchiectasis and septal line were evalvated on inspiratory scan and by air-trapping on expiratoryscan. RESULTS: On inspiratory scan, parenchymal micronodules were observed in one of 25 nonsmokers(4%), two of 16light smokers(13%) and five of 11 heavy smokers(45%); subpleural micronodules in two(8%), four(25%), two(18%);ground-glass attenuation in 0(0%), one(6%), three(27%); centrilobular emphysema in 0(0%), one(6%), three(27%);paraseptal emphysema in three(12%), 0(0%), five(45%); bronchial wall thickening in 0(0%), two(13%), one(9%),bronchiectasis in 0(0%), one(6%) two(18%) and septal line in one(4%), four(25%), two(18%). On expiratory scan,air-trapping was detected in 0 of 15 nonsmokers(0%), two of 17 light smokers(12%), and five of 11 heavysmokers(45%). Statistically significant differences between these three groups were found in parenchymalmicronodules(P=0.006), ground-glass attenuation(P=0.008), centrilobular emphysema(P=0.018), paraseptal emphysema(P=0.005) and air-trapping(P=0.013) between these three groups. CONCLUSION: According to the findings of HRCT,heavy smokers had higher frequency of parenchymal micronodules, ground-glass attenuation, centrilobular andparaseptal emphysema, and air-trapping than nonsmokers and light smokers.

Intrathoracic Major Vessels, Trachea and Main Bronchi: The Effect of Respiration on Size

PURPOSE: To evaluate the effect of respiration on the sizes of intrathoracic vasculature, and the trachea,and the main bronchus. MATERIALS AND METHODS: Seventeen volunteers (10males aged 20-39 years and 7 females aged20-39 years) underwent spiral CT, between the apex and lowest base of the lung, collimation was 10mm, pitch was 1,and images were obtained at breath hold forced end-inspiration and breath hold forced end-expiration. Crosssecional areas or diameters were measured in each respiration state at the aorta (ascending, descending, lowerthoracic) and great branches, the IVC (thoracic, abdominal), the SVC, pulmonary artery (right main, leftdescending) and the tracheobronchus (trachea, left upper bronchus). Changes in the size of vessels and airwaysbetween the respiration states were evaluated and compared between inspiration and expiration. RESULT: Duringbreath-hold forced end-inspiration CT, the ascending, descending, and lower thoracic aorta and itsbranches(brachiocephalic, left common carotid, left subclavian) as well as the thoracic IVC and SVC and the rightmain and left descending pulmonary arteries decreased in size: during breath-hold forced end-expiration CT, thesize of all these vessels increased. For the trachea, left upper lobe bronchus and abdominal IVC, the situationwas reversed. Statistically significant changes(p<0.05) were noted in the ascending aorta and descending aorta,the lower thoracic aorta, the thoracic and abdominal IVC, the SVC, the right main and left pulmonary arteries, andthe trachea. CONCLUSION: During respiration, changes in the size of the thoracic vasculature and airways isprobably due to changes in intrathoracic pressure. In the measurement and diagnosis of stenosis or dilatation inthe intrathoracic vesculature and airways, respiration states should therefore be considered.

Squalene-Induced Lipoid Pneumonia in Rabbits: High-Resolution CT and Pathologic findings

PURPOSE: To describe the HRCT and pathologic findings of squalene-induced lipoid pneumonia in rabbits. MATERIALS AND METHODS: Three ml of squalene was instilled into the trachea between the second and the third tracheal ring in 16 rabbits. Serial HRCT scans were obtained on day 4 (n=8), at 1 week (n=7), 2 weeks (n=1), 4 weeks(n=1), 6 weeks (n=2) and 20 weeks (n=1) after squalene instillation. With sacrifice of the rabbits pathology was reviewed at 1 week (n=3), 4 weeks (n=3), and 6 weeks (n=4) after CT scans. RESULTS: Lipoid pneumonia was induced in 8 rabbits; lesions were distributed mainly in the dependent posterior lung. On serial HRCT scans, airspace consolidation, as seen on an air-bronchogrm, and nodular opacities were early findings; these gradually diminshed and with time were replaced by nodular & linear opacities. Histologically, pulmonary fibrosis appeared one week after squalene instillation and progressed over time. Alveolar septal thickening and cuboidal change of the alveolar lining epithelium were more prominent at week 6. CONCLUSION: The early change of squalene-induced lipoidpneumonia in rabbits is the proliferation of intraalveolar macrophage, which is responsible for air-space consolidation with air-bronchograms on HRCT. Nodular and linear opacities on HRCT are due to the appearance of pulmonary fibrosis one week after squalene instillation, and its subsequent progression.