Guideline for the Surgical Management of Locally Invasive Differentiated Thyroid Cancer From the Korean Society of Head and Neck Surgery

The aim of this study was to develop evidence-based recommendations for determining the surgical extent in patients with locally invasive differentiated thyroid cancer (DTC). Locally invasive DTC with gross extrathyroidal extension invading surrounding anatomical structures may lead to several functional deficits and poor oncological outcomes. At present, the optimal extent of surgery in locally invasive DTC remains a matter of debate, and there are no adequate guidelines. On October 8, 2021, four experts searched the PubMed, Embase, and Cochrane Library databases; the identified papers were reviewed by 39 experts in thyroid and head and neck surgery. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence, and to develop and report recommendations. The strength of a recommendation reflects the confidence of a guideline panel that the desirable effects of an intervention outweigh any undesirable effects, across all patients for whom the recommendation is applicable. After completing the draft guidelines, Delphi questionnaires were completed by members of the Korean Society of Head and Neck Surgery. Twenty-seven evidence-based recommendations were made for several factors, including the preoperative workup; surgical extent of thyroidectomy; surgery for cancer invading the strap muscles, recurrent laryngeal nerve, laryngeal framework, trachea, or esophagus; and surgery for patients with central and lateral cervical lymph node involvement. Evidence-based guidelines were devised to help clinicians make safer and more efficient clinical decisions for the optimal surgical treatment of patients with locally invasive DTC.

Clinical Practice Guidelines for Oropharyngeal Dysphagia / 대한연하장애학회지

Objective@#Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one’s physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia. @*Methods@#Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology. @*Results@#Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended. @*Conclusion@#This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient's treatment goals.

Case of Papillary Thyroid Carcinoma with Subclinical Lateral Lymph Node Metastasis Presenting as Recurrence / 대한이비인후과학회지

Lateral neck metastasis is an independent risk factor of the loco-regional recurrence in papillary thyroid carcinoma (PTC). Ultrasonography (US) and computed tomography are frequently performed to diagnose the lymph node (LN) metastasis. However, some metastatic LNs can remain after initial treatment and can present as regional recurrences. A 19-year-old woman was diagnosed as having 1.99 cm PTC. No abnormal LNs was detected on preoperative CT and US. She underwent operation and radioactive iodine (RAI) therapy: seven months after RAI therapy, thyroglobulin level was elevated. However, no metastatic LNs were detected on neck CT, US and positron emission tomography-CT. Neck exploration was performed and metastatic PTC was diagnosed in bilateral level III and IV. A radiologist retrospectively reviewed the neck CTs taken before the first surgery and the second surgery. There was no significant difference in the LN appearances of two CTs. On both CT scans, all LNs were very small, homogenously enhanced, without calcification or cystic changes.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

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

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

Intramuscular Hemangioma in the Anterior Scalene Muscle Diagnosed by Core Needle Biopsy

Intramuscular hemangioma (IMH) is a rare, benign vascular lesion that frequently develops within skeletal muscles. Preoperatively, accurate diagnosis of IMH is often extremely difficult because of nonspecific clinical findings and the inaccuracy of fine-needle aspiration cytology. IMH is suspected in only 8% of preoperative diagnoses before surgical exploration. Here, we report a case of a 44-year-old man with a huge IMH in the anterior scalene muscle that was preoperatively diagnosed using ultrasonography-guided core needle biopsy, and was successfully treated based on preoperative clinical information.

Scapular Tip Free Flap for Head and Neck Reconstruction

OBJECTIVES: Head and neck reconstruction is still challenging in terms of esthetic and functional outcomes. This study investigated the feasibility of the angular branch-based scapular tip free flap (STFF). METHODS: This was a retrospective study of 17 patients undergoing maxillectomy and mandibulectomy and either primary or secondary reconstruction by STFF. This study included surgical, esthetic, and functional outcomes, and detailed data are presented regarding the flap, such as pedicle length, size of the harvested bone, and failure rate. Medical photographs were used to estimate the esthetic outcome, and computed tomography was used to check the flap status postoperatively. RESULTS: The data were collected from April 2013 to April 2014. Eight patients underwent maxillary reconstruction, and nine underwent mandibular reconstruction. Maxillary defects usually included unilateral alveolar structures and the palate; mandibular defects were usually those involving mandibular angle and short segment. Vein grafting was not required in any of the patients. Flap failure occurred in one of the 17 patients (5.9%) with successful reconstruction after revision. Of the eight maxillectomy patients, orbital revisions for diplopia after maxillary reconstruction were performed in two patients (25%), and oroantral fistula repair was performed in one patient (12.5%). CONCLUSION: This study demonstrated the reconstructive advantages of the angular branch-based STFF, long pedicle, low flap failure, 3-dimensional nature of bone and soft tissues (chimeric flap), and small rate of donor site morbidity with free ambulation. This flap is an excellent option for use in complex three-dimensional head and neck reconstruction.

Diagnostic Accuracy for Malignancy in Open Surgical Biopsy of Neck Lymph Nodes / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The open surgical biopsy (OSB) of neck lymph nodes is considered a definite diagnostic procedure; however, the diagnostic accuracy of this procedure has not been fully studied. Thus, we aimed to identify the false negative rates of OSB for malignancy and the possible causes of misdiagnosis that might severely affect patient prognosis. SUBJECTS AND METHOD: We extracted the data from 495 OSB of neck lymph nodes between 2005 and 2012. The diagnostic accuracy of OSB of neck lymph nodes was estimated based on re-biopsy. In addition, we reviewed possible clinical factors related to false negativity, cause of misdiagnosis and its clinical impacts. RESULTS: The false negative rate of OSB of neck nodes was 2.2% with a risk of 3.8% false diagnosis among subjects with initial 'benign' results. The cases of the initial misdiagnosis (n=7) had the dismal outcomes (4 deaths, 1 disease progression). The main cause of misdiagnosis was the failure to target the disease-affected lymph nodes (85.7%). Malignancy-related symptoms persisted in all cases of misdiagnosis, which required re-biopsy. CONCLUSION: Accurate targeting of lymph nodes, close monitoring of clinical symptoms and comparison of biopsy results with symptoms are very important to reduce false negativity for malignancy in OSB of neck lymph nodes.

The effect of remifentanil versus N2O on postoperative pain and emergence agitation after pediatric tonsillectomy/adenoidectomy / 대한마취과학회지

BACKGROUND: Remifentanil can be an alternative to N2O in general anesthesia. Intraoperative remifentanil may lead to acute opioid tolerance. This study aims to assess the effect of remifentanil substituted for 70% N2O on postoperative pain in children undergoing tonsillectomy/adenoidectomy. In addition, we evaluated the effect of remifentanil infusion on incidence of emergence agitation in these patients. METHODS: Eighty children, aged 2-12 years, undergoing tonsillectomy/adenoidectomy were randomly allocated to the N2O group (Group N; n = 40, sevoflurane and 70% N2O) or remifentanil group (Group R; n = 40, sevoflurane with remifentanil infusion at the rate of 0.17 microg/kg/min). In the recovery room, severity of pain and agitation were assessed by an investigator blinded to the assigned group. Time to eye opening and incidence of severe pain and agitation were compared between groups. Logistic regression was used to identify factors related to occurrence of severe pain and agitation. RESULTS: Number of patients with severe postoperative pain was 6 and 16 in groups N and R, respectively (P = 0.012). Incidence of emergence agitation was not significantly different between groups. Remifentanil infusion was a significant factor related to the occurrence of severe postoperative pain (P = 0.015), and age was inversely related to occurrence of emergence agitation (P = 0.001). CONCLUSIONS: In children undergoing tonsillectomy/adenoidectomy, intraoperative remifentanil infusion may increase incidence of severe postoperative pain compared to N2O, but it may not affect incidence of emergence agitation.

Genetic characterization of methicillin-resistant Staphylococcus aureus from humans and animals within the community / 대한수의학회지

Methicillin-resistant Staphylococcus (S.) aureus (MRSA) is one of the most important nosocomial pathogens worldwide and the emergence of this strain has become a major clinical problem. In this study, we investigated the prevalence of MRSA and their genetic characteristics in 69 S. aureus isolated from humans and animals. In human isolates, higher antimicrobial resistance rates were observed against penicillin (80.6%), followed by erythromycin (11.9%) and tetracycline (9.0%). All of them were susceptible to clindamycin, enrofloxacin, novobiocin, pirlimycin, trimethoprim/sulfamethoxazole and vancomycin. The resistance patterns in animal isolates were similar to those of human isolates. Two (2.9%) MRSA strains were isolated from human (n = 1) and animal (n = 1), and these isolates were confirmed as carrying the mecA gene. One isolate originating from human was resistant to 7 drugs and the other isolate derived from animal was resistant to 11 drugs. Staphylococcal cassette chromosome mec (SCCmec) variant IIIB was identified in animal isolate but SCCmec type of an isolate from human was not exactly determined. Two MRSA isolates showed unrelated PFGE pattern between them. Our results indicated although the frequency of MRSA isolates from humans and animals was low, a continuous surveillance and monitoring should be called for to prevent the contamination and spread of MRSA in the community. To our knowledge, this is the first time that SCCmec type variant IIIB was detected from animals in Korea.

Traumatic Fracture of the Stapes Suprastructure after Head Injury / 대한이비인후과학회지

Traumatic ossicular dislocation and fracture occur commonly after head injury. Dislocation of the incudo-stapedial and incudomalleolar joints are more common than isolated fractures of the ossicles. Fractures of the stapes suprastructure are relatively rare. We report two cases of isolated fracture of stapes suprastructure after head injury with a review of literatures, which resulted in excellent outcome after exploratory tympanotomy with ossicular reconstructions were carried out.

Clinical Review of Inverted Papilloma and Oncocytic Schneiderian Papilloma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Oncocytic schneiderian papilloma (OSP) is uncommon benign sinonasal neoplasm that arise from the sinonasal epithelium. Because of its rare incidence, OSP is not well-known by clinicians and report of this disease is uncommon. The aim of this study was to review the pathological features and variations of sinonsasl papillomas and to compare clinical behaviors of Inverted papiloma (IP) with OSP. SUBJECTS AND METHOD: A retrospective review and pathological assessment were performed on 99 sinonasal papilloma patients. Parameters for comparison included the origin site, radiologic finding, recurrence and malignancy rates. Predictive factors for recurrence and malignancy included histological variations of IP versus OSP. RESULTS: Eighty-eight patients (88%) were diagnosed with inverted papilloma and 11 patients (11%) were OSP. Recurrence developed in one patient with OSP (9%) and six patients with IP (7%). Six cases (7%) of carcinoma ex papilloma were seen only in IP. OSP was more often presented as a mixed form with inverted papilloma, rather than in the pure form. The histological variations and radiological findings, regardless of its difference, did not statistically impact recurrence rate and malignant transformation rate. CONCLUSION: The common mixed features of OPS and IP explains that these two lesions have the common etiological factor. In our study, there are no significant differentiations in clinical manifestation and prognosis. A larger number of cases for analysis would be necessary to confirm the properties of OSP.

Dissemination and tracking of Salmonella spp. in integrated broiler operation

Controlling Salmonella in integrated broiler operation is complicated because there are numerous potential sources of Salmonella contamination, including chicks, feed, rodents, wild poultry operations, and the processing plant. The objective of this study was to investigate the distribution of Salmonella through all phases of two integrated broiler operations and to determine the key areas related to the control of all known sources of infection. Two different Salmonella serotypes were observed at integrated broiler chicken company A. S. enteritidis, the predominant company A isolate, was consistently found in the breeder farm, hatcheries, broiler farms, and chicken slaughterhouse. At company B, a total of six different serotypes, S. heidelberg, S. senftenberg, S. enteritidis, S. blockley, S. gallinarum, and S. virchow, were detected. Although S. heidelberg was not found in the broiler farms, it was consistently found in the breeder farm, hatcheries, and chicken slaughterhouse. In addition, S. enteritidis was found in the hatcheries, broiler farm, and chicken slaughterhouse. In order to obtain the genetic clonality, 22 S. enteritidis isolates were digested with XbaI and analyzed by pulsed-field gel electrohporesis (PFGE). A difference in the PFGE pattern was found to be related to the origin of the integrated broiler operation. These data support the critical need to control Salmonella in breeder farms and hatcheries, and demonstrate important points related to the control of infection in large-scale poultry operations of Korea.

Alteration in gyrA and parC Gene Associated with Fluoroquinolone Resistance of Enterococcus spp. Isolated from Feces of Chicken

The purpose of this study was to investigate the fluoroquinolone resistance frequency of Enterococcus spp. from normal chicken feces and to analyse mutations of the gyrA and parC gene associated with fluoroquinolone resistance. Among 52 Enterococcus faecalis and 25 E. faecium isolates, 23 (44.2%) E. faecalis and 7 (28.0%) E. faecium were resistant to ciprofloxacin (CIP) by disc diffusion method. Genetic exchange in gyrA and parC gene among 2 CIP intermediate isolates and 15 CIP resistant isolates were found in the amino acid codon of Ser-83 and Asp-87, and Ser-80 and Glu-84, respectively. These mutants contained a change from Ser to Phe, Val, Tyr, Ile, Thr or Pro at codon 83 and from Glu to Gly or Leu at codon 87 in gyrA gene, and a change from Ser to Ile or Thr at codon 80 and from Glu to Asp or Lys at codon 84 in parC gene. The isolates with mutation in gyrA regardless of a mutation in parC showed high resistance (MIC > or =32 microgram/ml) to CIP, enrofloxacin, norfloxacin and ofloxacin. These results suggested that gyrA gene is the primary target for 4 fluoroquinolones resistance in Enterococcus spp.

Antibiotic Resistance and Genotypic Characterization of Escherichia coli Isolated from Pig Farm Environment

The use of antibiotics, including therapeutically in human and veterinary medicine, or as prophylaxis of growth promotion in animal husbandry, ultimately exerts selective pressure favorable for the propagation of antibiotic resistant bacteria. In this study we have determined the resistance for antibiotics of E. coli from pig farm environment, and investigate genetic relatedness by random amplification of polymorphic DNA (RAPD). Six farms were randomly selected in Gyeongsanman-do and Busan provinces for collecting samples from feces, manure and underground water. A total of 88 isolates from feces, 74 isolates from manure and 1 isolate from underground water were analyzed by antibiotic resistance and RAPD. Antibiotic resistance testing was performed by disk diffusion method using 16 antibiotics. The highest percentage of antibiotic resistance of isolates from feces and manure was found to the following antibiotics; tetracycline (100% and 100%), sulfamethoxazole/trimethoprim (60.2% and 62.2%), streptomycin (50.0% and 68.9%), chloramphenicol (56.8% and 56.8%), ampicillin (50.0% and 81.1%) and cephalothin (50.0% and 51.4%). Of isolates from feces and manure, 22.7% and 20.3% showed multiple resistance to 4 and 5 antibiotics, respectively. The isolates from GE pig farm showed six RAPD patterns. A single pattern, RAPD-C, was predominat in feces isolates (50.0%) and manual isolates (46.7%), and the rest of feces isolates showed RADP-A, B and E pattern and manure isolates showed D and E pattern. One isolate from underground water showed F pattern. The appearance of multiresistant in E. coli isolates from pig farms environment is a problem of major concern of public health and RAPD may offer an useful tool of discrimination for the epidemiological investigation.