Appropriateness of the use of Emergency Medical Services and Propensities Toward Choice by Local Residents of Hospitals

PURPOSE: Inappropriate use or misuse of emergency medical services (EMS) is a potential waste of resources and a possible diversion of needed service from another patient in need. One of the most serious consequences of inappropriate use of EMS is emergency department crowding. The purpose of this study was to evaluate the appropriateness of EMS use and the propensity of local residents in Daegu to choose particular hospitals. METHODS: We obtained study data from Jan. to Feb. 2009 using a prospective survey of patients or their companies that had used EMS. The survey was done by a senior emergency physician who rode in an ambulance with 119 crew members during on-scene assessments and en route to the hospital. The severity of illness/injury was evaluated using the START system/CRAMS scale. We analyzed the appropriateness of EMS use and hospital transport in relation to the severity of the patients problem. We also identified factors that directly influence choice of hospitals. RESULTS: Forty-six cases (36.8%) chose an inappropriate hospital. In 89 cases (71.2%), choice of hospital was done by the patient or his guardian. The most common factor that directly influenced hospital choice was the hospital the patients identified with (50%). Appropriateness of transport to the hospital correlated with problem severity evaluated by the EMS team and by trauma patients (p<0.05). Transport to a higher level hospital (39%) was selected about ten fold more often than transport to a lower level hospital (4%). CONCLUSION: The appropriateness of local EMS use should be improved with respect to many factors. Local residents have a propensity to choose a large or university hospital for a variety of reasons. Local residents should be continuously educated for appropriative EMS use.

Treatment Results and Voice Analysis after Laser Cordectomy for Glottic T1 Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: For the treatment of glottic T1 cancer, several methods such as laser cordectomy, conservative laryngeal surgery and radiation therapy are possible. This study was performed to investigate the utility of laser cordectomy in the oncological and phonetic aspects. MATERIALS AND METHOD: Eighteen patients with glottic T1 cancer, who had undergone laser cordectomy at Kosin Medical Center from March, 1997 to July, 2001, were retrospectively investigated. The method of the operation was classified according to European Laryngological Society Classification. We analysed intraoperative complication, the duration of admission, postoperative complication, and tumor recurrence. Twelve patients were phonetically analysed using MATLAB and have undergone perceptual analysis. Videostroboscopy was performed for every patient to analyze the mechanism of phonation. As a control group, six normal persons were used. RESULTS: Intraoperative complications were not found in any of the 18 patients, but 5 patients who had suspicious lesions during following up after operation, have undergone biopsy which gave negative results. Among 4 patients who had granulation tissues, 2 patients were spontaneously regressed, and the other 2 patients have undergone removal of tissue with no recurrences. The vocal parameters such as Fo, S.D.Fo, jitter, shimmer and NHR differed significantly between the surgery group and the control group. The parameters maximum phonation time, speech rate and speech intelligiblity did not differ between two groups. CONCLUSION: Laser cordectomy for glottic T1 cancer provides time-and cost-effectiveness, a low level of morbidity, excellent local control rate, and acceptable voice quality.

A Comparison of Ho's, Fourth-edition, and Fifth-edition American Joint Committee Staging Systems for Nasopharyngeal Carcinoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The incidence of nasopharyngeal carcinoma (NPC) is reported to be high in South China and Hong-Kong. For that reason, the Ho's staging system has been used in the Hong-Kong area, while the American Joint Committee on Cancer (AJCC) staging system has been commonly used in western countries. The fifth-edition staging system defines new rules for classifying NPC. The purpose of this study was to find out whether the fifth-edition of the AJCC staging system is better than Ho's and the fourth-edition AJCC staging system in predicting the prognosis of NPC. MATERIALS AND METHOD: Fifty NPC patients of World Health Organization type II and type III were restaged according to the Ho's staging system, the fourth-edition AJCC and the fifth-edition AJCC staging systems. The disease specific survival rate was calculated by T category, N category and stage grouping for each staging system. RESULTS: The fifth-edition of AJCC showed good distribution compared with other systems in stage classification and also showed statistical significance in the disease specific survival rate between early carcinoma (stage I-II) and advanced carcinoma (stage III-IV). On the survival curve of T and N categories, the fifth-edition of AJCC showed statistical significance in the disease specific survival rate between T1-2 and T3-4 group, and also between N0-1 and N2-3 group. But Ho's staging system showed similar statistical results to the fifth-edition of AJCC, except for higher concentration of patients at stage III. The fourth-edition of AJCC didn't show any statistical significance among categories of T, N and the stage groups. CONCLUSION: In considering the poorer survival rates resulting from the cranial nerve or intracranial invasion and bilateral, or lower neck lymph node metastasis, the extensive invasion to adjacent regions and lymph node metastasis may have an influence on the prognosis. As far as prognostic categories are concerned, the fifth-edition of AJCC appears to be an improvement over other system. So, we concluded that the fifth-edition of AJCC staging system is better than the fourth-edition of AJCC and Ho's staging system to predict the prognosis of NPC.

A Case of Cavernous Hemangioma of the Pyriform Sinus / 대한이비인후과학회지

Approximately 60% of all hemangiomas occur in the head and neck region, but hypopharyngeal hemangiomas are very rare. The diagnoses were classified depending on histopathologic findings into cavernous hemangioma, capillary hemangioma and mixed hemangioma. The treatments are sclero theraphy, surgical excision, vascular ligation, cryotheraphy, electrical cautery, ND Yag laser excision, and CO2 laser excision. We have experienced a case of hemangioma in the medial wall of the left pyriform sinus. In our case, we removed it "en bloc" without difficulty with the endoscopic CO2 laser. The histologic diagnosis was a cavernous hemangioma with no evidence of malignancy. One year after surgery, there was no evidence of residual tumors or recurrence. We report this case of cavernous hemangioma in the hypopharynx.

A Case of Neurilemmoma of the Brachial Plexus / 대한이비인후과학회지

Neurilemmoma is a benign, solitary tumor which may occur from the nerve sheath of the peripheral, sympathetic and cranial nerves. Although it occurs most frequently in the head and neck region, especially in the acoustic nerve and the vagus nerve, the neurilemmoma of the brachial plexus is rare. We have experienced a case of neurilemmoma in the brachial plexus. Surgical excision was performed by anterior supraclavicular approach. The mass was removed completely, sparing the nerve function. We report this case with literature review.

Complications Following Thyroid Surgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Despite the fact that the rate of complications is constantly decreasing, the immediate and severe complications of thyroid surgery emphasize the need for precise surgical techniques and to provide patients with the most benefical treatment that results in lower morbidity. To clarify the safety of thyroid surgery, 147 thyroidectomy cases were reviewed. MATERIALS AND METHODS: From April 1998 through March 2000, 147 thyroidectomies were performed at the otolaryngologic department. The risk of recurrent laryngeal nerve lesion is based on the number of nerves at risk, and the risk of hypocalcemia is based on the number of patients undergoing bilateral procedures, or contralateral surgery in patients previously operated on. The risk of superior laryngeal nerve injury is based on the number of all thyroidectomies. RESULTS: The number of nerves at risk was 210. The rate of postoperative permanent recurrent laryngeal nerve palsy was 1.4% (3/210), which is iatrogenic. Four recurrent nerves (1.9%) invaded by cancer were sacrificed intentionally. Transient paralysis was found in 1.4% of the cases (3/210). Transient superior laryngeal nerve injury was found in 0.7% (1/147), all within one month of recovery. Of 89 patients undergoing dissection of both thyroid lobes, 1.1% (1/89) developed postoperative permanent hypocalcemia. Transient postoperative hypocalcemia was found in 7 patients (7.9%), with a recovery period ranging from one to two weeks. Postoperative bleeding, infection, and seroma were not noted in this study. CONCLUSION: The data strongly indicate that careful surgical techniques, understanding of anatomic variation and surgical experiences hold the clue for a low rate of complications following thyroid surgery.

Imaging and Acoustic Study of Laryngectomees after the Amatsu Tracheoesophageal Shunt Operation / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The two most important methods for voice rehabilitation after total laryngectomy are tracheoesophageal speech and esophageal speech. The former can be obtained in several ways, for example, by the primary Amatsu tracheoesophageal (T-E) shunt operation or by the use of a low-resistance valve such as the Provox prosthesis. The purpose of this investigation was to study the anatomy and physiology of the neoglottis and to evaluate the vocal quality of tracheoesophageal speech. MATERIALS AND METHODS: A total of 12 patients, who had undergone the Amatsu T-E shunt operation after total laryngectomy, were analyzed using the stroboscopy, laryngofiberscopy, videofluoroscopy, and computerized speech lab. RESULTS: With stroboscopy, the neoglottis was split from left to right in 3 patients and in 9 patients, the direction of opening and closure of rheeoglottis was anterior-posterior. The regular vibratory features were observed in patients with a shortened visible vibratorvsegment. The results of videofluoroscopy indicate that the location of the vibration was mostly situated between C3 and C5. The cervical esophagus closure during tracheoesophageal phonation was located at a level between C7-T2. CONCLUSION: The anatomical and morphological characteristics of the neoglottis was related to the healing process after operation. The neoglottis was considered to be formed by the thyropharyngeal muscle, and concentric contraction under subneoglottic extension was formed by the contraction of the cervical esophagus.

Management of Osteoradionecrosis of the Mandible in Patients with Oral and Oropharyngeal Cancers / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Osteoradionecrosis (ORN) of the mandible is one of the most serious complications following radiotherapy for oral and oropharyngeal cancer. However, the predisposing factors and clinical course of ORN are variable and its proper management is currently undetermined. The objective of this study is to review our ORN cases and evaluate the treatment methods. PATIENTS AND METHODS: We retrospectively reviewed 57 cases of oral and oropharyngeal cancers, where patients received combined surgery and radiotherapy from 1990 to 1998. Osteoradionecrosis occurred in 5 cases, and we evaluated the predisposing factors, clinical course and results of treatments. Four patients were treated with radical sequestrectomy and open reduction of mandible. Of these four patients, three received the combined treatment with hyperbaric oxygen (HBO) therapy, and one received the conservative treatment. RESULTS: Four ORN cases occurred at the lateral mandibulotomy site and one case arose at the opposite mandibular body unrelated to osteotomy. The interval between ORN and radiotherapy was so variable as 3 to 140 months. Four patients were successfully treated with the combined surgical and HBO therapies (3 cases) or with the conservative treatment (1 case). The remaining case could not be controlled by surgical treatment without HBO. CONCLUSION: Osteoradionecrosis usually occurred at lateral mandibulotomy sites, especially combined with sagittal partial mandibulectomies. We recommend that lateral mandibulotomies should, whenever possible, be avoided if the radiotherapy is planned postoperatively. And the patients who received radiotherapy at the mandible should be observed for osteoradionecrosis for long time. Our treatment results suggest that a combined surgery with HBO therapy can be a primary treatment modality for ORN.

A Case of Primary Malignant Melanoma in Parotid Gland / 대한이비인후과학회지

Reports on primary malignant melanoma arising from parotid gland are extremely rare. We report a case of malignant melanoma which was presented in the parotid gland with no other primary lesions detectable. The main clinical presentation was a progressively enlarging, asymptomatic mass in the parotid gland. The 29-year-old patient underwent a total parotidectomy and right modified radical neck dissection type I. The patient was subsequently treated by postoperative high-dose radiotherapy. The most common symptom of primary malignant melanoma in the parotid gland is a progressively enlarging, asymptomatic, firm, and fixed mass. Radical excision is the treatment of choice. The role of radiotherapy, chemotherapy and immunotherapy remains unclear. Although rare, primary malignant melanoma should be considered in the differential diagnosis of parotid gland tumor. We report the case with a review of the literature.