Clinical Practice Guideline: Clinical Efficacy of Nasal Surgery in the Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians’ grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians’ care based on their experience and assessment of individual patients.

Alterations in the Swallowing Function According to the Severity of Obstructive Sleep Apnea Syndrome / 대한연하장애학회지

Objective@#Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder that can have a significant impact on the quality of life. According to recent studies, some OSAS patients exhibit swallowing abnormalities, such as the premature entry of food into the hypopharynx, and laryngeal penetration. We aimed to evaluate the swallowing function of OSAS patients and compare swallowing-related parameters between OSAS severity groups through a video fluoroscopic swallowing study (VFSS). @*Methods@#Ninety-two participants with a symptom of snoring were enrolled in this retrospective study. Eighty-four participants were diagnosed with OSAS by polysomnography. The subjects were evaluated using the apnea-hypopnea index (AHI) and divided into four groups, namely non-OSAS, mild, moderate, and severe OSAS. Since all patients reported choking symptoms, they underwent VFSS and were evaluated for penetration or aspiration. The temporal parameters evaluated were oral transit time, pharyngeal transit time, and pharyngeal delay time. The movement parameters assessed were the distance, duration, and velocity of laryngeal elevation (LE). @*Results@#Penetration was detected in six OSAS patients, but aspiration was not observed in any patient. Seventy-four patients showed vallecular and pyriform sinus residue, although the amount was not significantly large. There was no significant difference in any of the temporal parameters between the groups except pharyngeal transit time with 10 ml of yogurt. In the Pearson’s correlation and multivariate linear regression analysis, LE distance and LE velocity, both correlated with AHI scores with 5 ml of liquid, 10 ml of liquid, and 10 ml of yogurt, respectively. @*Conclusion@#Severe OSAS patients showed longer and faster hyolaryngeal movement while swallowing, which may be a compensatory movement to prevent penetration or aspiration.

Clinical Practice Guideline: Nasal Irrigation for Chronic Rhinosinusitis in Adults

The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.

Performance of an Automated Polysomnography Scoring Using Noxturnal Program versus Manual Scoring / 대한이비인후과학회지

Background and Objectives@#A lack of investigators for polysomnography has risen due to increased demand since health insurance started to cover the cost of the test. We examined the reliability of the automated scoring of polysomnography, which has been deployed to improve this imbalance.Subjects and Method We analyzed the data of 20 patients who underwent level 1 polysomnography from April 1 to July 27, 2019. The software from Noxturnal (Nox Medical) was used for the scoring of the Polysomnography data. Each of the polysomnographic data was scored both by the automated scoring system and by a skilled technician. @*Results@#Twenty patients were analyzed. There was no significant difference between automated scoring and manual scoring in sleep latency, apnea index, and rapid eye movement sleep stage ratio. However, the concordance rate of the sleep stage by epoch was 83.32%, and there was a significant difference with regards to apnea-hypoapnea index (AHI) and respiratory disturbance index (RDI). Two obvious errors were noted in the automated scoring that could be easily fixed; the failure to recognize wakefulness during sleep and the fragmentation of respiratory events. When two errors were corrected, many differences in polysomnography parameters, including AHI and RDI, were eliminated. @*Conclusion@#It showed 80% coincidence of epoch in the sleep stage between the automated scoring and manual scoring. However, there was no difference in AHI and RDI when the fragmented respiratory events of the automated scoring were adjusted. Therefore, automated scoring is considered to be useful if only a little modification could be made.

Epistaxis as an Initial Manifestation of Juvenile Xanthogranuloma: A Case Report / 대한이비인후과학회지

Juvenile xanthogranuloma (JXG) is a rare benign histiocytic tumor, which was first described by Adamson in 1905. JXG typically presents as solitary or multiple yellow-brown skin nodules in infants, most often on the head, neck or upper trunk. Extracutaneous forms are rare and there are only several cases reported in the nasal cavity up to date. Previous cases were presented with the mass effect such as nasal obstruction. We recently experienced a pediatric patient with epistaxis and the nasal endoscopy suggested pyogenic granuloma. However, biopsy of the mass revealed JXG. Herein, we report a case of disseminated juvenile xanthoma misdiagnosed as pyogenic granuloma.

Severe laryngomalacia in a 1-month infant with Marfan syndrome

Severe respiratory difficulty can be more prominent, when combined with severe pectus excavatum and cardiovascular manifestations in infants with Marfan syndrome. There have been few reports on severe laryngomalacia as a cause of severe respiratory difficulty in an infant with Marfan syndrome. A 1-month-old boy was admitted due to severe respiratory difficulty. Immediately after birth, he had dysmorphic features, such as micrognathia, wrinkles on the forehead, and down-slanting palpebral fissures. On echocardiography, aortic root dilation with a mitral valve prolapse was observed. Due to severe laryngomalacia accompanied by severe respiratory difficulty and feeding difficulty, a partial epiglottectomy was performed at 1 month of age. After the surgery, suprasternal retraction and inspiratory stridor disappeared, and he started gaining weight with improvement in respiratory difficulty. On whole exome sequencing, a missense mutation on the FBN1 gene (c.3560A> C on exon 29, p.His1187Pro, calcium-binding epidermal growth factor-like #21) was identified. Despite higher perioperative risk due to comorbidities in Marfan syndrome, early intervention of laryngomalacia can be helpful in improving quality of life even in infants with Marfan syndrome.

The Antibiotic-Vaseline Soaked Cotton Pledget as an Adjuvant Material for Endoscopic Endonasal Fungal Ball Removal

Background and Objectives@#Treatment choice for fungal ball is endoscopic endonasal removal. However, it is not easy to remove fungal elements from the maxilla using only an endonasal approach. To overcome this difficulty, we introduced a cotton pledget technique and evaluated its efficacy through a cadaveric study and clinical research.Materials and Method: A cadaveric study was performed using 10 half heads of seven cadavers. The ease and safety of the cotton pledget technique were compared to those of a previously reported technique. In clinical research, we enrolled 52 patients who underwent surgery with the cotton pledget technique and 36 patients who underwent surgery using the conventional endoscopic approach. Demographic factors, preoperative Lund-Mackay (LM) score, sinonasal outcome test (SNOT) score, surgical morbidity, and incomplete removal rate were analyzed. @*Results@#The cadaveric study showed that the cotton pledget technique was easier (p=0.011) than the conventional technique. In addition, clinical evaluation showed that the cotton pledget group had significantly lower incomplete removal rate than that of the control group (p=0.010). @*Conclusion@#The cotton pledget technique is an easy and safe method that enables fungal ball removal more effectively than the conventional technique without need for inferior meatal antrostomy (IMA) or the Caldwell-Luc (CL) approach.

The Efficacy of Nasal Surgery on Pharyngeal Airway / 대한이비인후과학회지

Background and Objectives@#Nasal surgery is known to improve the quality of life in patients with obstructive sleep apnea; however, its effect on the airway structure is little known. This study attempted to identify the impact of nasal surgery on the pharyngeal airway structure.Subjects and Method We enrolled in the study patients who underwent nasal surgery from July 2015 to March 2018 due to nasal obstruction with severe snoring or sleep apnea. Patients with palate surgery or previous history of airway surgery were excluded. Demographic factors, symptoms regarding nasal obstruction, sleep study, preoperative cephalometry, and postoperative 3-month cephalometry were taken into account and analyzed. We also performed a subgroup analysis according to the severity of sleep apnea. @*Results@#Sixty-three patients were enrolled in this study. Soft palate thickness showed no significant change. Pre and postoperative soft palate thickness were 10.82±3.00 and 11.11±3.35 (p=0.261), respectively. However, the pharyngeal airway space was enlarged via nasal surgery from 12.05±3.35 to 13.04±3.35 (p=0.006), respectively. The subgroup analysis showed that the pharyngeal airway was mainly enlarged in the patients with lower Apnea-Hypopnea Index (AHI). @*Conclusion@#Although nasal surgery does not reduce soft palate thickness, it can enlarge the pharyngeal airway space. The effect of surgery would be more prominent in patients with AHI of lower than 15 event/hour (p=0.005) as nasal surgery alone does not affect the pharyngeal airway of patients with AHI greater than 15.

SLEEP-GOAL: A multicenter success criteria outcome study on 302 obstructive sleep apnoea (OSA) patients

@#Objective: To demonstrate SLEEP-GOAL as a more holistic and comprehensive success criterion for Obstructive Sleep Apnoea (OSA) treatment. Methods: A prospective 7-country clinical trial of 302 OSA patients, who met the selection criteria, and underwent nose, palate and/or tongue surgery. Pre- and post-operative data were recorded and analysed based on both the Sher criteria (apnoea hypopnea index, AHI reduction 50% and <20) and the SLEEP-GOAL. Results: There were 229 males and 73 females, mean age of 42.4±17.3 years, mean BMI 27.9±4.2. The mean VAS score improved from 7.7±1.4 to 2.5±1.7 (p<0.05), mean Epworth score (ESS) improved from 12.2±4.6 to 4.9±2.8 (p<0.05), mean body mass index (BMI) decreased from 27.9±4.2 to 26.1±3.7 (p>0.05), gross weight decreased from 81.9±14.3kg to 76.6±13.3kg. The mean AHI decreased 33.4±18.9 to 14.6±11.0 (p<0.05), mean lowest oxygen saturation (LSAT) improved 79.4±9.2% to 86.9±5.9% (p<0.05), and mean duration of oxygen <90% decreased from 32.6±8.9 minutes to 7.3±2.1 minutes (p<0.05). The overall success rate (302 patients) based on the Sher criteria was 66.2%. Crosstabulation of respective major/minor criteria fulfilment, based on fulfilment of two major and two minor or better, the success rate (based on SLEEP-GOAL) was 69.8%. Based solely on the Sher criteria, 63 patients who had significant blood pressure reduction, 29 patients who had BMI reduction and 66 patients who had clinically significant decrease in duration of oxygen <90% would have been misclassified as “failures”. Conclusion: AHI as a single parameter is unreliable. Assessing true success outcomes of OSA treatment, requires comprehensive and holistic parameters, reflecting true end-organ injury/function; the SLEEP-GOAL meets these requirements

A Missed and Delayed Detected Fish Bone Impaction in Subglottis / 대한이비인후과학회지

Laryngeal foreign body can be a life-threatening emergency. Respiratory distress, aphonia, and cyanosis may occur in quick succession. However, in case of a non-obstructive laryngeal foreign body, symptoms can be indolent, but the hazardous foreign body can nevertheless put the patient in danger. To prevent life-threatening consequences, early detection based on symptoms is imperative. This case, which presented with usual symptoms of anterior neck pain and throat discomfort without respiratory symptoms and an unusual site of laryngeal foreign body, finally turned out to be an impacted fish bone in the subglottis.

Patients' Characteristics according to Allergic Sensitization in Chronic Rhinitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Chronic rhinitis is divided into allergic rhinitis (AR) and nonallergic rhinitis (NAR), both of which have similar symptoms but differ in treatment approaches. For the diagnosis of AR, allergen-specific immunoglobulin E (IgE) tests along with characteristic symptoms are required. However, these tests are costly and not always practicable. The purpose of this study was to investigate how symptoms respond differently to different allergen sensitization or sensitized allergen. SUBJECTS AND METHOD: We retrospectively reviewed 1661 patients who underwent multiple allergen simultaneous test (MAST) for chronic rhinitis symptoms. The total nasal symptom (TNS) scores of these patients from 2006 to 2014 were assessed for rhinorrhea, nasal obstruction, itching, and sneezing. Patients were classified as AR and NAR according to the results of MAST and their association with symptoms. RESULTS: There were 1021 patients designated to the AR group and 640 patients to the NAR. The AR group had lower age, higher TNS, and higher serum IgE levels than the NAR group. In addition, sneezing and itching were more common in the AR group. Furthermore, sneezing was a positive predictor for seasonal allergen sensitization. On the other hand, itching was a positive predictor for perennial allergen sensitization. CONCLUSION: AR and NAR patients showed different demographic characteristics and symptoms. These results may be helpful in classifying and treating patients with chronic rhinitis, especially when the allergen specific IgE test cannot be performed.

Minimally Invasive Horizontal Intercartilaginous Incision during Tracheostomy – A Cadaveric Study / 체질인류학회지

The paper describes a minimally invasive tracheostomy technique that uses an intercartilaginous incision without resection of the tracheal cartilage and discusses its feasibility. A total of 20 adult cadavers (13 males and 7 females) were included in this study. The distance from the arch of the cricoid cartilage to the thyroid isthmus, maximal displacement of the thyroid isthmus, number of tracheal rings underneath the thyroid isthmus, and maximally opened distance resulting from an intercartilaginous incision were measured. The mean distance from the arch of the cricoid cartilage to the thyroid isthmus was 21.4±5.0 mm. The thyroid isthmus mainly overlaid the 3rd and 4th tracheal rings. The mean maximal displacement of the thyroid isthmus was 9.0±2.8 mm. Minimally invasive tracheostomy via an intercartilaginous incision is a feasible technique. A skin incision 2 cm below the cricoid cartilage enables exposure of the thyroid isthmus and anular ligament between the 2nd and 3rd tracheal rings. The intercartilaginous incision allows sufficient space for the tracheostomy tube. An intercartilaginous incision without resection of a tracheal ring can be a good alternative tracheostomy technique, especially for patients who require transient tracheostomy.

Patients' Characteristics according to Allergic Sensitization in Chronic Rhinitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES@#Chronic rhinitis is divided into allergic rhinitis (AR) and nonallergic rhinitis (NAR), both of which have similar symptoms but differ in treatment approaches. For the diagnosis of AR, allergen-specific immunoglobulin E (IgE) tests along with characteristic symptoms are required. However, these tests are costly and not always practicable. The purpose of this study was to investigate how symptoms respond differently to different allergen sensitization or sensitized allergen.SUBJECTS AND METHOD: We retrospectively reviewed 1661 patients who underwent multiple allergen simultaneous test (MAST) for chronic rhinitis symptoms. The total nasal symptom (TNS) scores of these patients from 2006 to 2014 were assessed for rhinorrhea, nasal obstruction, itching, and sneezing. Patients were classified as AR and NAR according to the results of MAST and their association with symptoms.@*RESULTS@#There were 1021 patients designated to the AR group and 640 patients to the NAR. The AR group had lower age, higher TNS, and higher serum IgE levels than the NAR group. In addition, sneezing and itching were more common in the AR group. Furthermore, sneezing was a positive predictor for seasonal allergen sensitization. On the other hand, itching was a positive predictor for perennial allergen sensitization.@*CONCLUSION@#AR and NAR patients showed different demographic characteristics and symptoms. These results may be helpful in classifying and treating patients with chronic rhinitis, especially when the allergen specific IgE test cannot be performed.

Congenital Cholesteatoma of Mastoid Temporal Bone and Posterior Cranial Fossa Treated with Transmastoid Marsupialization / 대한이비인후과학회지

A congenital cholesteatoma is a benign mass formed from the keratinizing stratified squamous epithelium. It usually occurs in young children's anterosuperior part of the middle ear. A congenital cholesteatoma which originates from mastoid temporal bone or expands to posterior cranial fossa is rare. Standard treatment of an intracranial cholesteatoma is surgical removal with craniotomy. A 69-year-old woman was diagnosed with a congenital cholesteatoma of mastoid temporal bone that expanded to the posterior cranial fossa, which was successfully treated with transmastoid marsupialization without craniotomy. This is a first documented case of a congenital cholesteatoma of mastoid temporal bone that expanded to posterior cranial fossa, which was successfully treated with transmastoid marsupialization without craniotomy.

Suitability of Ethanol-Glycerin Embalming Cadavers for the Training of Human Anatomy / 체질인류학회지

This study evaluates the suitability of cadavers embalmed by the ethanol-glycerin fixative for the dissection course of medical students and the hands-on dissection workshop of clinicians. Five cadavers were embalmed by two different methods: two formalin-phenol fixation (FPF) and three ethanol-glycerin fixation (EGF) cadavers. The measurement of physical and chemical characteristics including ranges of motion (ROM), bacterial and fungal culture tests, and ultrasonography were performed for each cadaver. The EGF cadavers were evaluated to be significantly more suitable than FPF cadavers for the physical and chemical characteristics including color, texture, elasticity, wetness (softness), skin incision, vessel ligation and suture, decollement, odor, and irritant. In shoulder, elbow, and wrist joints, ROMs of the EGF cadavers were statistically more than those of the FPF except for elbow extension. On bacterial and fungal culture tests at 8 weeks after carrying out of refrigerator, one bacteria were detected in one EGF cadaver; however, some bacteria and fungi could be detected in all FPF cadavers. The ultrasound images of abdominal organ and thigh musculature could be more clearly detected in the EGF cadavers than those of FPF cadavers. These results indicate that the EGF method had a sufficient antibiotic effect and produced cadavers with flexible joints and a high tissue quality suitable for various cadaveric dissection courses.

Donor-Site Morbidity Following Minimally Invasive Costal Cartilage Harvest Technique

OBJECTIVES: Autologous costal cartilage is a promising alternative for mastoid obliteration. However, donor-site morbidities of the chest wall limit the use of this graft. To address this issue, we have developed a minimally-invasive technique of harvesting costal cartilage and report donor site morbidity associated with the procedure. METHODS: Donor site morbidities were evaluated for 151 patients who underwent costal cartilage harvest, canal wall down mastoidectomy, and mastoid obliteration. Pain and cosmetic concern were evaluated via visual analogue scale (VAS). Scars were evaluated via the modified Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). Postoperative complications were assessed during the follow-up period. RESULTS: The mean duration of noticeable pain was 5.3 days post operation. The mean VAS score for pain was 3.0 of 10 on the first day after the operation and gradually declined. At the 6 months post operation, the mean VAS cosmetic score at the costal cartilage harvest site was 0.6 of 10. The mean VSS score was 9.5 out of 10 total, and the mean POSAS score was 23.27 out of 110 total. CONCLUSION: The minimally-invasive chopped costal cartilage harvest technique resulted in acceptable pain, cosmetic concern, and postoperative complications for most patients. There were no major postoperative complications. Costal cartilage is an acceptable donor for mastoid obliteration in canal wall down mastoidectomy, especially in the context of the extremely low donor site morbidity of the minimally-invasive technique presented in the study.

Intratympanic Drug Injection for Inner Ear Disease / 대한이비인후과학회지

During treatment of inner ear diseases, the blood-cochlear barrier limits the drug delivery into the cochlea. Intratympanic drug injection for inner ear diseases is a safe procedure where drugs reach high concentrations in the cochlea and systemic side effects are minimized. This paper reviews the updated status of intratympanic drug injections for the treatment of inner ear disease. Intratympanic drug injection is an effective procedure for the control of inner ear disorders such as Meniere's disease and sudden sensorineural hearing loss. Although the effect of intratympanic injection on tinnitus and noise-induced hearing loss is open to discussion, its indications could be extended, like as drug, gene, and cell-based therapy.

Vascular Leiomyoma in the Head and Neck Region: 11 Years Experience in One Institution

OBJECTIVES: Vascular leiomyoma is an uncommon benign tumor of smooth muscle origin that arises from the muscularis layer of blood vessel walls. We report our experiences with the clinical manifestations, pathologic characteristics, and management of vascular leiomyoma in the head and neck. METHODS: The clinical records of 12 patients with vascular leiomyoma of the head and neck in the 11-year period were reviewed retrospectively. RESULTS: The 12 patients included nine men and three women. The locations of the tumors were variable, including nasal cavity, auricle, hard palate, upper lip, upper eyelid, and supraclavicular space. All but three patients reported an asymptomatic spherical mass; the other three patients complained of intermittent epistaxis or unilateral nasal obstruction resulting from the tumor originating in the nasal cavity. All tumors were painless. Computed tomography consistently revealed a well-defined, intensely enhanced small mass on the mucosa. No case was dignosed corretly as vascular leiomyoma before surgical excision. All patients underwent localized surgical excision of the tumor without recurrence. Five of 12 tumors (42%) were of solid type, four (33%) were of venous type, and three (25%) were of cavernous in histological classification. The histologic type was not related to gender, site of occurrence, and presence of pain. CONCLUSION: Vascular leiomyoma presents as a small, painless mass in various locations of the head and neck region. Localized surgical excision is the only way to make the diagnosis and yields excellent results.

Delayed Facial Nerve Paralysis after Tympanomastoid Surgery: The Potentiality of Fungal Infection and Treatment / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The purpose of this study was to assess the clinical courses and clinical outcomes of delayed facial nerve paralysis (DFNP) after middle ear and mastoid surgery. SUBJECTS AND METHOD: In our hospital, postoperative DFNP occurred in 13 cases among the patients who underwent ear surgery from December 2000 to February 2010. During the same period, another 4 cases with postoperative DFNP were diagnosed at a local clinic. We assessed the degree of DFNP by using House-Brackmann grade (HBG) and separated 8 patients in grade II, 6 patients in grade III and 3 patients in Grade IV. Among 17 patients, DFNP occurred after open cavity mastoidectomy in 11 cases and after closed cavity mastoidectomy in the rest of 6 cases. RESULTS: Among 17 postoperative DFNP, fungal infections were found in three patients. Patients for whom antifungal agent was relatively delayed in application, their condition did not improved. CONCLUSION: After treatment, most of patients recovered within 1 month and there were no other associated infection during hospitalization. We suggest that antifungal agents should be used as soon as possible when patients complain about DFNP following open cavity mastoidectomy.

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.