Guidelines for the Use of Botulinum Toxin in Otolaryngology From the Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force

The Korean Society of Laryngology, Phoniatrics and Logopedics created a task force to establish clinical practice guidelines for the use of botulinum toxin (BT) in otolaryngology. We selected 10 disease categories: spasmodic dysphonia, essential vocal tremor, vocal fold granuloma, bilateral vocal fold paralysis, Frey’s syndrome, sialocele, sialorrhea, cricopharyngeal dysfunction, chronic sialadenitis, and first bite syndrome. To retrieve all relevant papers, we searched the CORE databases with predefined search strategies, including Medline (PubMed), Embase, the Cochrane Library, and KoreaMed. The committee reported 13 final recommendations with detailed evidence profiles. The guidelines are primarily aimed at all clinicians applying BT to the head and neck area. In addition, the guidelines aim to promote an improved understanding of the safe and effective use of BT by policymakers and counselors, as well as in patients scheduled to receive BT injections.

A Case of Spontaneous Cervical Hematoma caused by Parathyroid Adenoma / 대한두경부종양학회지

Spontaneous cervical hematomas could lead to life-threatening complications, and aneurysms, retopharyngeal abscesses, parathyroid adenomas, laryngeal cysts, and neurogenic tumors should be distinguished as possible underlying causes. Symptoms accompanying spontaneous cervical hematoma include cervical swelling, ecchymosis, dysphagia, dyspnea and hoarseness. We recently experienced a case of spontaneous cervical hematoma in a 52-year-old woman, who initially presented with cervical swelling after severe coughing two days ago. Resultingly parathyroid adenoma was finally confirmed after mass excision. Therefore, we present this unique case with a review of the literature.

A Case of Solitary Metastatic Deposit in the Orbital Rim from Follicular Thyroid Cancer / 대한두경부종양학회지

Follicular thyroid carcinoma (FTC) is the second most common thyroid cancer, following papillary carcinoma. Metastasis to the orbital rim from FTC is very rare. We recently experienced a case of FTC with metastasis to the orbital rim in a 74-year-old woman, who initially presented with a huge thyroid mass and an asymptomatic solitary orbital rim lesion. The solitary orbital rim lesion was suspected to be a separate disease entity such as lymphoma from the preoperative imaging, but bone metastasis from FTC was finally confirmed after orbital rim resection and total thyroidectomy. During follow-up, the patient presented multiple bone metastasis, so the solitary orbital rim lesion was considered a clinical sign of systemic metastasis from FTC. Therefore, we present this unique case with a review of the literature.

A Case of Chronic Tonsillitis Mimicking a Parapharyngeal Space Tumor / 대한이비인후과학회지

Parapharyngeal space (PPS) tumors are extremely rare, composing only 0.5% of all head and neck tumors. The PPS is shaped like an inverted pyramid bounded by the skull base superiorly and hyoid bone inferiorly. Recently, we experienced a 55-year-old female patient who visited the clinic with a presumed PPS tumor that had been incidentally identified by neck MRI. The patient underwent surgery for the removal of tumor by transoral approach following tonsillectomy. However, contrary to the initial expectations, no tumors were visible at the operative field and only observed were the evidence of chronic inflammatory tissues within the removed tonsil. To date, chronic follicular tonsillitis mimicking a PPS tumor has not been reported in the literature. Therefore, we report this case with a brief discussion of points to consider supported by a review of relevant literature.

Targeting Fatty Acid Metabolism in Head and Neck Cancer / 대한이비인후과학회지

Reprogramming of cellular metabolism is an important, emerging, and universal hallmark of cancer which has received considerable attention during the recent era of cancer research. Cancer cells show characteristic alterations in glucose metabolism in order to fulfill the needs of biosynthesis for tumor proliferation and growth. However, under certain circumstances such as invasion and metastasis, cancer cells are prone to metabolic stress and will require different strategies to meet the high energetic demand from cancer progression. From various metabolic rewiring mechanisms, cancer cells adopt other metabolic pathways with alternative nutrient sources. Therefore, targeting cancer metabolism holds promising but great challenge caused by the metabolic plasticity of cancer cells. This review will discuss characteristic cancer metabolism in detail with special focus on lipid metabolism which is gathering increasingly keen interest, in order to find novel therapeutic approaches to head and neck cancer. By understanding and exploiting the synthesis, oxidation, and storage of fatty acids, we could investigate potential strategies to block cancer proliferation and progression.

A Case of Multiple Pharyngocutaneous Fistulae Following Post-Operative Concurrent Chemoradiotherapy for Oropharyngeal Cancer / 대한이비인후과학회지

Pharyngocutaneous fistula is a readily encountered complication that occurs after surgery for laryngopharyngeal cancer. The development of pharyngocutaneous fistula increases hospitalization, delays postoperative adjuvant treatment, and can lead to serious complications such as wound infection and carotid artery rupture. Transoral robotic surgery (TORS) is actively being performed as a standard procedure for surgery of pharyngeal and laryngeal cancers. Many reports verified that TORS is advantageous in terms of perioperative outcomes such as decreased hospitalization and reduced rate of postoperative complications, free flap reconstruction, and tracheostomy or gastrostomy tube dependence relative to open surgery. However, careful selection of patients is mandatory and there are some critical points to consider in optimal treatment outcomes. Recently, we experienced a 47-year-old patient with tonsillar cancer who underwent lateral oropharyngectomy by TORS and radical neck dissection. Unfortunately, multiple pharyngocutaneous fistulae occurred following postoperative concurrent chemoradiotherapy (CCRT). Multiple phrayngocutaneous fistulae following TORS and postoperative CCRT have not been reported in the literature. Therefore, we report this case with a brief discussion supported by a review of the relevant literature.

Clinical Analysis of Laryngeal Tuberculosis: Recent 10 Years’ Experience in a Single Institution

Background and Objectives@#The overall incidence of laryngeal tuberculosis (LT) has generally decreased over the recent years, yet there is still a discrete population of patients newly diagnosed with the disease. This study is aimed to examine the patients with LT over the recent 10 years and to investigate the changes in clinical pattern with respect to the past period.Materials and Method A retrospective review has been performed on 20 patients who have been initially diagnosed with LT between 2005 and 2015. @*Results@#The age of the patients ranged from 25 years to 95 years with an average age of 45.6 years. Seventeen patients (85%) showed hoarseness, which was the most common clinical symptom. Most affected lesion was the true vocal cord. Laryngoscopic examination showed various clinical manifestations: polypoid 30%, granulomatous 25%, nonspecific 25%, ulcerative 20%. A variety of methods were used for diagnostic confirmation of LT [acid-fast bacilli (AFB) smear 45%, AFB culture 40%, polymerase chain reaction 30%, surgical pathology 45%]. Coexisting pulmonary tuberculosis (PT) was detected in 10 patients (50%). Relative to the patients with inactive PT or normal lung status, those with active PT showed higher incidence of laryngeal lesions located in areas other than true vocal cord (p=0.050). @*Conclusion@#Based on the analytic results from this study, laryngologists should recognize the changes in the recent clinical patterns of LT and always be ready for clinical suspicion of this disease on such atypical laryngeal findings which can often mimic laryngeal malignancies to provide the pertinent treatment.

Clinical Analysis of Laryngeal Tuberculosis: Recent 10 Years’ Experience in a Single Institution

Background and Objectives@#The overall incidence of laryngeal tuberculosis (LT) has generally decreased over the recent years, yet there is still a discrete population of patients newly diagnosed with the disease. This study is aimed to examine the patients with LT over the recent 10 years and to investigate the changes in clinical pattern with respect to the past period.Materials and Method A retrospective review has been performed on 20 patients who have been initially diagnosed with LT between 2005 and 2015. @*Results@#The age of the patients ranged from 25 years to 95 years with an average age of 45.6 years. Seventeen patients (85%) showed hoarseness, which was the most common clinical symptom. Most affected lesion was the true vocal cord. Laryngoscopic examination showed various clinical manifestations: polypoid 30%, granulomatous 25%, nonspecific 25%, ulcerative 20%. A variety of methods were used for diagnostic confirmation of LT [acid-fast bacilli (AFB) smear 45%, AFB culture 40%, polymerase chain reaction 30%, surgical pathology 45%]. Coexisting pulmonary tuberculosis (PT) was detected in 10 patients (50%). Relative to the patients with inactive PT or normal lung status, those with active PT showed higher incidence of laryngeal lesions located in areas other than true vocal cord (p=0.050). @*Conclusion@#Based on the analytic results from this study, laryngologists should recognize the changes in the recent clinical patterns of LT and always be ready for clinical suspicion of this disease on such atypical laryngeal findings which can often mimic laryngeal malignancies to provide the pertinent treatment.

Clinical Characteristics and Management of Saccular Cysts: A Single Institute Experience

OBJECTIVES: A saccular cyst is defined as a dilated saccule of the larynx, filled with mucus, and is located between the false vocal cords and the thyroid cartilage. Although this uncommon laryngeal condition is benign in nature, it could lead to dyspnea, stridor, and airway obstruction, depending on its size and location. Furthermore, some saccular cysts have been associated with laryngeal carcinoma. This study aimed to characterize this rather uncommon laryngeal condition to aid in determining the proper management of this pathology. METHODS: Medical records were retrospectively reviewed of all patients with saccular cysts diagnosed and treated between 2006 and 2017 at a tertiary otolaryngologic care center. RESULTS: Seven patients with saccular cysts were identified (male:female=2:5; mean age, 34.1 years); two were pediatric patients. Surgical intervention was performed in all patients by laryngo-microsurgery using CO2 laser. There was no recurrence after the initial surgical treatment. CONCLUSION: Saccular cysts can be managed endoscopically using CO2 laser, without requiring an external approach. Therefore, an endoscopic approach should be actively considered for an optimal treatment outcome.

A Case of Unexpected Clinostomum complanatum Infection Initially Presenting as Foreign Body in Pharynx

A 46-year old man visited our outpatient clinic with complaint of foreign body sensation in throat after consuming raw freshwater fish 5 days ago. Laryngoscopic examination revealed a motile worm attached on posterior pharyngeal wall. The worm was removed using biopsy forceps under transnasal endoscopy and evidently identified as Clinostomum complanatum after microscopic examination. Patient’s subjective foreign body sensation of throat and hyperemia of laryngeal mucosa remained for approximately 2 weeks post-removal, which were eventually resolved after administration of non-steroidal anti-inflammatory drug and anti-refluxant drug for 2 weeks. Treatment was ended at three weeks since the first visit. C. complanatum infections in humans are rare, and only four cases have been reported in Korea. Symptoms resembling pharyngitis or laryngitis occurs by consumption of raw, infected freshwater fish and treatment is done by mechanically removing the parasite.

The Usefulness of Postoperative Direct Voice Therapy in Vocal Polyps / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Previous studies have suggested the usefulness and importance of postoperative voice therapy, for which there are indirect and direct methods. The aim of this study was to evaluate the efficacy of treatment according to different voice therapy methods. SUBJECTS AND METHOD: Patients with vocal polyp were divided into three groups. Group 1 received direct voice therapy after phonomicrosurgery and Group 2 indirect voice therapy after phonomicrosurgery. Group 3 did not receive any voice therapy. RESULTS: Perceptual, acoustic, aerodynamic voice outcome parameters differed significantly between pre and post-operative treatments. In almost all of the voice analysis, Group 1, who underwent direct voice therapy, improved more significantly compared with Group 2 and 3. CONCLUSION: Postoperative voice therapy following phonomicrosurgery may be an effective adjuvant treatment in patients with vocal polyps. In particular, direct voice therapy can be effective for improving postoperative voice outcome.

Crosstalk Mechanisms Following Targeted Therapy in Head and Neck Cancer / 대한이비인후과학회지

Head and neck squamous cell carcinoma has emerged as the sixth most commonly occurring cancer worldwide and despite advances in diagnostics and therapeutics, the treatment results and survival outcomes still remain poor, especially in advanced cancers. Due to the complexity of the local anatomic structures and the importance as vital functioning organs, the head and neck area following conventional treatment modalities such as surgery, chemotherapy, or radiotherapy often result as a devastating consequence both esthetically and functionally. In order to minimize the treatment related sequelae and at the same time maximize treatment effect, tumor-specific molecular targeted therapy has become an area under active research. Several molecular targeted agents, including the representative epidermal growth factor receptor (EGFR)-inhibitors have been developed and its therapeutic effects investigated. However, therapeutic resistance has newly risen as a main problem following targeted therapy due to a variety of resistance mechanisms. This review article looks at the major acquired resistance mechanisms following targeted agents administration including EGFR inhibitors and many others and strategies to overcome the resistance to achieve precision medicine.

Anterolateral Thigh Thickness Measurement in Positron Emission Tomography-Computed Tomography for the Prediction of Free Flap Reconstruction Outcomes in Head and Neck Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Anterolateral thigh (ALT) flaps are commonly used for head and neck surgery reconstruction. However, a thick ALT often leads to long operation times. Therefore, ALT thickness on a preoperative non contrast image of positron emission tomography-computed tomography (PET-CT) scan was measured to predict surgical outcome. SUBJECTS AND METHOD: The correlation between ALT thickness and total reconstruction time was analyzed in 106 patients. The differences in ALT thickness between the successful and compromised-flap groups were analyzed retrospectively. RESULTS: Median ALT thickness was 4.49 mm, and total reconstruction time was 190 min. Total reconstruction time was significantly correlated with ALT thickness (p=0.019). ALT thickness, body mass index (BMI), total reconstruction time and ischemia time were significantly greater in the compromised-flap group than in the successful group. In the multivariate analysis, only BMI and ischemia time were predictors for the compromised flap. CONCLUSION: ALT thickness measured on a non-contrast image of PET-CT scan is useful as a surgical outcome predictor with respect to total reconstruction time. A further study may suggest the risk of a thick ALT in a compromised flap in head and neck reconstruction using an ALT free flap.

Hypoxia Induces Epithelial-Mesenchymal Transition in Follicular Thyroid Cancer: Involvement of Regulation of Twist by Hypoxia Inducible Factor-1alpha

PURPOSE: Although follicular thyroid cancer (FTC) has a relatively fair prognosis, distant metastasis sometimes results in poor prognosis and survival. There is little understanding of the mechanisms contributing to the aggressiveness potential of thyroid cancer. We showed that hypoxia inducible factor-1alpha (HIF-1alpha) induced aggressiveness in FTC cells and identified the underlying mechanism of the HIF-1alpha-induced invasive characteristics. MATERIALS AND METHODS: Cells were cultured under controlled hypoxic environments (1% O2) or normoxic conditions. The effect of hypoxia on HIF-1alpha, and epithelial-to-mesenchymal transition (EMT) related markers were evaluated by quantitative real-time PCR, Western blot analysis and immunocytochemistry. Invasion and wound healing assay were conducted to identify functional character of EMT. The involvement of HIF-1alpha and Twist in EMT were studied using gene overexpression or silencing. After orthotopic nude mouse model was established using the cells transfected with lentiviral shHIF-1alpha, tissue analysis was done. RESULTS: Hypoxia induces HIF-1alpha expression and EMT, including typical morphologic changes, cadherin shift, and increased vimentin expression. We showed that overexpression of HIF-1alpha via transfection resulted in the aforementioned changes without hypoxia, and repression of HIF-1alpha with RNA interference suppressed hypoxia-induced HIF-1alpha and EMT. Furthermore, we also observed that Twist expression was regulated by HIF-1alpha. These were confirmed in the orthotopic FTC model. CONCLUSION: Hypoxia induced HIF-1alpha, which in turn induced EMT, resulting in the increased capacity for invasion and migration of cells via regulation of the Twist signal pathway in FTC cells. These findings provide insight into a possible therapeutic strategy to prevent invasive and metastatic FTC.

Rosai-Dorfman Disease of the Nasal Cavity and Nasopharynx / 대한이비인후과학회지

Rosai-Dorfman disease is a rare disorder of unknown etiology and is usually associated with benign proliferation of hematopoietic and fibrous tissue that often manifests in the head and neck region. The most common clinical presentation of this entity is bilateral, nontender cervical lymphadenopathy, but an extranodal form of the disease may develop in up to 43% of patients. We report a case of extranodal Rosai-Dorfman disease occurring in the nasal cavity and the nasopharynx. A 25-year-old male visited the clinic with a complaint of nasal obstruction for several months. Mass originating from anterior portion of septum and nasopharyngeal cavity was observed by endoscopy. Endoscopic guided incisional biopsy of the lesion was performed. The histopathologic findings revealed clusters of large, foamy histiocytes with abundant clear cytoplasm, lymphophagocytosis, and heavy infiltration of lymphocytes and plasma cells, which are the key features of Rosai-Dorfman disease.

A Case of Vestibular Schwannoma Treated with Revision Middle Cranial Fossa Approach to Preserve Facial Nerve Function and Hearing Ability / 대한이비인후과학회지

The aim of surgery for vestibular schwannoma is to accomplish complete tumor removal while preserving facial function and hearing ability. The middle cranial fossa approach represents one such surgical approach for resection of vestibular schwannoma with hearing preservation. As more experience has been gained with this approach, hearing preservation rates have increased. However, even if gross tumor removal is done completely, residual tumor can show regrowth microscopically. Such residual vestibular schwannoma may be treated by different options. We present a case of residual vestibular schwannoma treated with revision middle cranial fossa approach to preserve facial function and hearing ability.

Effects of Levocetirizine on Quality of Life in the Patients with Allergic Rhinitis

BACKGROUND AND OBJECTIVES: Allergy is a chronic disorder with undesirable consequences on the quality of life (QoL). The first aim of this study is to evaluate the impact of allergy on the QoL and to show the correlation between symptoms and categories of the QoL. The second purpose is to determine whether treatment with levocetirizine improves the QoL among allergic rhinitis patients. MATERIALS AND METHODS: A total of 412 allergic patients answered the questionnaire and its sensitivity was checked to validate its usefulness in asthma and allergic rhinitis patients. To evaluate the effect of applying levocetirizine for 1 month on the QoL among allergic rhinitis patients, a total of 94 subjects were assessed with the questionnaire and analyzed (paired t-test). To evaluate its effect on the symptoms of allergic rhinitis for the duration of 2 and 4 weeks, a total of 100 subjects were analyzed (repeated ANOVA) with the symptom questionnaire. RESULTS: Besides the physical symptoms, patients suffered from activity restriction, emotional problems, difficulty in being examined, and dissatisfaction with health status. The correlation between the questionnaire and the QoL was statistically significant. After treatment, the QoL and symptoms, except nasal congestion, were significantly improved. CONCLUSION: The questionnaire can be beneficial in assessing the QoL among allergic patients. Treatment with levocetirizine provides improvement in the QoL and lowers the symptoms score among allergic rhinitis patients.