Prevalence and characteristics of vagus nerve variations on neck ultrasonography

Purpose@#We aimed to evaluate the true prevalence and characteristics of vagus nerve (VN) variations using the carotid artery (CA) and the internal jugular vein (C-I axis). @*Methods@#We examined patients who underwent neck ultrasonography (US) conducted by a single operator. A VN variation was defined as a VN located anterior or medial to the C-I axis. The subtypes of VN variation were classified as anterolateral, anteromiddle, anteromedial, and medial based on the relative location of the VN to the CA. The primary outcome parameters were the prevalence of VN variations and differences according to side, age, and sex. @*Results@#Out of 536 patients, right and left VN variations were identified in 20 (3.7%) and 186 (34.7%), respectively (P<0.001). The anteromiddle type was the commonest type observed on both sides. Eight right (1.5%) and 50 left VNs (9.3%) were located <2 mm from the lateral border of the ipsilateral thyroid gland (P<0.001). The prevalence of VN variations in male and female patients was 42.1% and 32.7%, respectively (P=0.029), and that in patients aged <20, 20-39, 40-59, and ≥60 years was 23.8%, 22.5%, 34.4%, and 47.4%, respectively (P<0.001). @*Conclusion@#Variations in the VN position were relatively common on US. The variations primarily involved the left VN in the lower cervical region, and an increasing prevalence with age was observed.

A Case of Parathyroid Carcinoma with Spontaneous Infarction / 대한두경부종양학회지

Parathyroid carcinoma is very rare malignant neoplasm, accounting for less than 0.005% of all cancers. Most parathyroid carcinoma is a functioning tumor that causes hyperparathyroidism, leading to hypercalcemia. We report a parathyroid carcinoma case that was suspicious for spontaneous infarction of cancer, leading to resolution of hypercalcemia. A 29-year-old male visited our hospital presenting with right neck swelling and pain. He has been experiencing frequent urolithiasis for four years but laboratory tests showed normal serum calcium level. Right vocal cord paresis was identified with laryngoscopy. Ultrasonography revealed a 3.7 × 3.5 cm mass in the right thyroid containing a focal cystic portion. Computed tomography confirmed the presence of a low-density right thyroid mass. Right thyroid lobectomy was performed and pathological evaluation revealed parathyroid carcinoma with central necrosis. We report this very rare case with a literature review.

Application of Ultrasonography for Safe Flap Elevation at the Learning Period of Transoral Thyroidectomy: A Technical Report / 대한이비인후과학회지

Transoral thyroidectomy using the vestibular approach has achieved excellent cosmetic outcomes without leaving any visible scars. However, concerns have been raised on how to prevent complications, such as skin perforation and anterior jugular vein injury, especially in the learning period. This is because working space is generally created via blind and blunt dissection using a blunt dilator through small vestibular incisions unfamiliar to beginners. Herein, we explain an intraoperative real-time ultrasound technique employed in transoral thyroidectomy to safely elevate a skin flap while avoiding any damage to the flap and anterior jugular vein in the learning period.

A Case of Solitary Fibrous Tumor Presenting as Lower Neck Mass / 대한두경부종양학회지

Solitary fibrous tumor (SFT) is rare mesenchymal tumor usually arising from pleura. SFT can be found at all anatomic site in our body but incidence of SFT is much lower in head and neck region especially at lower neck area.We found a case of SFT that presented as a lower neck mass in a 41-year old woman. Ultrasonography showed a 3×1cm sized hypoechoic mass in the intermuscular fat plane of left lower neck, and computed tomography showed a well circumscribed, low-density mass with contrast enhancement. Fine needle aspiration showed no malignant cells with abundant red blood cells, but it was not possible to completely rule out malignant tumors or nodules clinically. Surgery was performed to make a definitive diagnosis and histopathology showed tightly packed, round to fusiform cells with staghorn shaped vessels at microscopic examination. The tumor cell were positive for CD34 but negative for CD31 and S-100 protein.

A Case of Hemophagocytic Lymphohistiocytosis Presenting with Neck Mass in a Child / 대한두경부종양학회지

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening one syndrome of excessive immune activation. This immune dysregulation disorder is prominently associated with cytopenias and combinations of clinical signs and extreme inflammation symptoms. For survival, it is important to diagnose early and treat appropriately. We report a case of 10 years old boy who was admitted to the hospital with a month history of fever and cervical lymph node enlargement. There were signs of hemophagocytic histiocytosis in the lymph node and bone marrow. The etiology, diagnosis, and treatment of hemophagocytic lymphohistiocytosis are reviewed.

A Case of Intravenous Pyogenic Granuloma Found as a Neck Mass / 대한두경부종양학회지

Intravenous pyogenic granuloma, commonly known as intravenous lobular capillary hemangioma, is a rare benign tumor of the vein. It rarely occurs in the neck, and its character is not enough to diagnosis clinically. It could be diagnosed with preoperative radiologic examinations such as ultrasound and computed tomography and typical pathologic findings that demonstrate lobules of multiple capillaries lined with flattened endothelial cells admixed with fibromyxoid stroma. The authors report a case of a 32-year-old male who presented with a palpable neck mass for one month with a review of the literature. He was successfully treated with resection, including the tumor and normal external jugular vein, without any complications.

A Case of Hemophagocytic Lymphohistiocytosis Presenting with Neck Mass in a Child / 대한두경부종양학회지

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening one syndrome of excessive immune activation. This immune dysregulation disorder is prominently associated with cytopenias and combinations of clinical signs and extreme inflammation symptoms. For survival, it is important to diagnose early and treat appropriately. We report a case of 10 years old boy who was admitted to the hospital with a month history of fever and cervical lymph node enlargement. There were signs of hemophagocytic histiocytosis in the lymph node and bone marrow. The etiology, diagnosis, and treatment of hemophagocytic lymphohistiocytosis are reviewed.

A Case of Intravenous Pyogenic Granuloma Found as a Neck Mass / 대한두경부종양학회지

Intravenous pyogenic granuloma, commonly known as intravenous lobular capillary hemangioma, is a rare benign tumor of the vein. It rarely occurs in the neck, and its character is not enough to diagnosis clinically. It could be diagnosed with preoperative radiologic examinations such as ultrasound and computed tomography and typical pathologic findings that demonstrate lobules of multiple capillaries lined with flattened endothelial cells admixed with fibromyxoid stroma. The authors report a case of a 32-year-old male who presented with a palpable neck mass for one month with a review of the literature. He was successfully treated with resection, including the tumor and normal external jugular vein, without any complications.

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.

Prediction of Location of the Parotid Tumors that Cross Over Anatomical Criteria for Facial Nerve on Computed Tomography / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To find more accurate way to determine the location of parotid tumors that cross anatomical criteria for the facial nerve (FN). SUBJECTS AND METHOD: Two hundred patients were included in the study and retrospectively studied. Five anatomical criteria were used to predict the location of parotid tumors on computed tomography (CT). Deep portion of tumors was measured and then, cut-off value was obtained after receiver operator curve analysis. The location of tumor was predicted by using the cut-off value and by the conventional way, in which the side where most of the tumor is located is determined as the tumor site. RESULTS: The parotid tumors were located in superficial lobes in 148 cases, and in deep lobes in 52 cases by operative record. The tumors that cross the anatomical criteria were defined as ‘crossing tumor.’ The cut-off values for prediction of ‘crossing tumor’ location on CT were 6.7 mm for anatomical line, 6.4 mm for FN line, 11.2 mm for retromandibular vein, 4.9 mm for Utrecht line and 3.8 mm for Conn's arc. The accuracy of 5 anatomical criteria for ‘crossing tumor’ was between 55.9% and 81.6% when the cut-off value was used, whereas the accuracy was between 25.7% and 68.9% when conventional way was used. CONCLUSION: In cases of ‘crossing tumor,’ the cut-off value obtained by measurement of deep portion of tumor can be applied to improve the diagnostic performance for the prediction of tumor location.

Prediction of Location of the Parotid Tumors that Cross Over Anatomical Criteria for Facial Nerve on Computed Tomography / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES@#To find more accurate way to determine the location of parotid tumors that cross anatomical criteria for the facial nerve (FN).SUBJECTS AND METHOD: Two hundred patients were included in the study and retrospectively studied. Five anatomical criteria were used to predict the location of parotid tumors on computed tomography (CT). Deep portion of tumors was measured and then, cut-off value was obtained after receiver operator curve analysis. The location of tumor was predicted by using the cut-off value and by the conventional way, in which the side where most of the tumor is located is determined as the tumor site.@*RESULTS@#The parotid tumors were located in superficial lobes in 148 cases, and in deep lobes in 52 cases by operative record. The tumors that cross the anatomical criteria were defined as ‘crossing tumor.’ The cut-off values for prediction of ‘crossing tumor’ location on CT were 6.7 mm for anatomical line, 6.4 mm for FN line, 11.2 mm for retromandibular vein, 4.9 mm for Utrecht line and 3.8 mm for Conn's arc. The accuracy of 5 anatomical criteria for ‘crossing tumor’ was between 55.9% and 81.6% when the cut-off value was used, whereas the accuracy was between 25.7% and 68.9% when conventional way was used.@*CONCLUSION@#In cases of ‘crossing tumor,’ the cut-off value obtained by measurement of deep portion of tumor can be applied to improve the diagnostic performance for the prediction of tumor location.

Cervical Bronchogenic Cysts Mimicking Papillary Thyroid Carcinoma on Ultrasound / 대한이비인후과학회지

Here, we describe two cases of cervical bronchogenic cysts mimicking thyroid cancer on ultrasound (US), introducing some sources of diagnostic error with the aim of improving the understanding of cervical bronchogenic cysts. In these cases, US demonstrated ill-defined nonhomogeneous hypoechoic nodules at the inferior pole of the thyroid gland, exhibiting several echogenic foci that mimicked microcalcification of papillary thyroid carcinoma. Although cervical bronchogenic cysts can be presented as highly suspicious thyroid nodules on US, recognition of this disease entity and comprehensive understanding of its presentation can allow an appropriate diagnostic process without unnecessary diagnostic surgery.

Expert's Consensus on Terminology of Auditory Perceptual Assessment in Voice Disorder / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The purpose of this study was to conduct a preliminary study to develop a standardized guideline for terminology necessary to describe auditory perception qualitatively and quantitatively in voice disorders in the Korean language. SUBJECTS AND METHOD: At first, a subjective questionnaire for Korean translation and definition of 25 auditory perceptual assessment terms proposed by Titze was answered by six speech-language pathologists. Secondly, a new questionnaire that was reconstructed with objective items based on the responses to the first questionnaire was completed by 14 experts who had experience on voice disorder for more than 10 years in Korea. In both questionnaires, the necessity of 32 auditory perceptual assessment terms selected from the 25 terms defined by Titze, GRBAS and CAPE-V was surveyed. RESULTS: The consensus on the Korean translation of auditory perceptual assessment terms was moderate (52.6%) between experts. The terms ‘ rough’ and ‘ shimmer’ demonstrated highest consensus of 85.7%. The consensus on Korean definition of auditory perceptual assessment terms was also moderate (61.6%). The term ‘ yawny’ showed complete consensus (100%). The necessity of auditory perceptual assessment terms varied with terms, but showed high consensus. CONCLUSION: It is necessary to develop and apply various standardized vocabulary terms for clinical evaluation so that they can express pathology and physiological characteristics during vocalization. In addition, despite the fact that there are a lot of auditory-perceptual terms, there is a lack of knowledge about voice quality terms, suggesting the need to promote and educate the developed voice quality terms.

Tactile Sensation Recovery after Parotidectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: One of the common complications after parotidectomy is a decrease in skin sensation around the parotid gland. This is known to be associated with damage to the great auricular nerve (GAN). The purpose of this study was to investigate the pattern of tactile sensory recovery after parotidectomy and the difference in sensory recovery according to the preservation or sacrifice of the GAN. SUBJECTS AND METHOD: Fifty-two patients who underwent parotidectomy were enrolled in this study. The Touch Test Sensory Evaluator was used to measure the minimum tactile threshold value at 6 sites around the auricle before surgery and at 1 week, 1, 3, 6 and 12 months after surgery. RESULTS: The tactile threshold was the highest at 1 month after parotidectomy in all 6 sites. After 1 month, the threshold value gradually decreased until 12 months after surgery. However, the threshold was not completely recovered to the preoperative threshold level. At least one branch and the main trunk of GAN were preserved in 39 patients; one of GAN branches was preserved but the main trunk of GAN was partially injured in 3 patients, and the main trunk of GAN was completely injured in 10 patients. The tactile sensory recovery showed no significant differences in relation to the GAN status. CONCLUSION: The tactile sensory value kept decreasing up to one month following parotidectomy and then gradually recovered. However, the tactile sensory did not recover completely even one year after surgery. The GAN preservation did not affect tactile sensory recovery.

Ultrasound of Head and Neck: Anatomy / 대한이비인후과학회지

Ultrasound can be usefully applied as the first modality in various head neck lesions. Ultrasound enables the clinicians to diagnose most head, neck mass immediately and ultrasound-guided procedures, including fine needle aspiration, core-needle biopsy, drainage of abscess, and intraoperative localization of lesion provide the clinicians the chance to improve the quality of practice. The usefulness of ultrasound can be much amplified when ultrasound is performed by the clinicians and the first step to manipulate the ultrasound is to understand the normal ultrasound appearance of head and neck structures. The aims of this paper are to provide basic tips for ultrasound scanning of head and neck and to illustrate the ultrasonographic anatomy of head and neck.

Preoperative Measurement of Submandibular Gland Stone Size / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The choice of optimal treatment methods among various gland preserving procedures including transoral surgery, sialendoscopy and extracorporeal lithotripsy for submandibular stones is mainly determined by the size of the stone. We tried to assess the accuracy of ultrasonography (USG) and computerized tomography (CT) for the preoperative estimation of submandibular gland stone size. SUBJECTS AND METHOD: We retrospectively reviewed the medical records of 251 patients who were treated for submandibular stones from January 2008 to December 2014. Eighty patients who checked both preoperative USG and CT were included. Preoperative USG and CT measurements of the submandibular stones were compared to postoperative measurements of removed stones. Effects of stone location and presence of acute infection on preoperative measurements were also assessed. RESULTS: The mean submandibular gland stone size was 6.60+/-3.8 mm by USG, 7.23+/-4.0 mm by neck CT and 7.89+/-4.7 mm by the postoperative measurement. USG and CT showed good correlation with the postoperative measurement (correlation coefficient 0.912 and 0.940, respectively). The location of stone and presence of combined infection showed no significant impact on the accuracy of USG and CT measurement. CONCLUSION: USG and neck CT showed high accuracy for predicting submandibular gland stone size. However, it should be taken into consideration that the stone size could be greater than that shown by preoperative measurement.

Cribriform-Morular Variant of Papillary Thyroid Carcinoma Associated with Familial Adenomatous Polyposis / 대한이비인후과학회지

We report a case of cribriform-morular variant of papillary thyroid carcinoma associated with familial adenomatous polyposis. A 21-year-old woman presented with multiple, well-defined, oval shaped thyroid nodules, which showed hypo-echoic and solid mixed with some cystic components by ultrasound, and poorly enhancing and low dense by CT scan. Cytological finding was compatible with papillary carcinoma. Total thyroidectomy was performed and nodules were palated soft. Histologic analysis confirmed the diagnosis of cribriform-morular variant of papillary thyroid carcinoma. Familial adenomatous polyposis, thereafter, was diagnosed by family history and colonoscopy, and preventive colectomy was performed.

Correlation Between the Visual Field Test and Multifocal Electroretinogram in Patients with Diabetic Retinopathy

PURPOSE: To evaluate the macular function by a multifocal electroretinogram (mfERG) in patients with diabetic retinopathy (DR), and to assess the correlation between responses of mfERG and the threshold of the visual field test (VF). METHODS: The records of patients with DR (16 eyes, 16 patients) and control subjects (14 eyes, 14 subjects) were retrospectively reviewed. mfERG and VF were divided into Ring 1, Ring 2 and Ring 3 at 6-degree intervals from the central macula. The correlation between the amplitude/peak time and the threshold of each ring was analyzed. RESULTS: In patients with DR, the amplitude was decreased in all areas, the peak time was delayed in Ring 2 and the threshold was decreased in Rings 2 and 3, compared to control subjects. The amplitude of mfERG and the threshold of VF showed statistically significant positive correlations in Rings 2 and 3 (p < 0.05). The peak time of mfERG and the threshold of VF showed statistically significant negative correlations in Ring 3 (p < 0.05). CONCLUSIONS: The threshold of VF was more significantly correlated with the amplitude than with the peak time of mfERG in patients with DR. mfERG and VF were useful tests to assess the macular function, and alteration of macular function was early detected because two tests were conducted at the same time.

Effects of Fungi and Eosinophils on Mucin Gene Expression in Rhinovirus-Infected Nasal Epithelial Cells

PURPOSE: Fungi, rhinoviruses (RVs), and eosinophils are associated with upper respiratory diseases. We evaluated the effects of fungal stimulation and eosinophil co-culture on the expression of mucin genes in RV-infected nasal polyp epithelial cells. METHODS: Nasal polyp epithelial cells were obtained from chronic rhinosinusitis patients. Cultured epithelial cells were stimulated with Alternaria and Aspergillus with or without RV-16 infection. The epithelial cells were co-cultured with eosinophils for 16 h. MUC4, MUC5AC, MUC5B, and MUC8 mRNA expressions in the epithelial cells were quantified using real-time RT-PCR. To determine the underlying mechanism, nuclear factor-kappaB (NF-kappaB), activator protein-1 (AP-1), and mitogen-activated protein kinase (MAPK) inhibitors were used to inhibit mucin gene expression. RESULTS: Fungi and RV-16 induced mucin gene expression in nasal polyp epithelial cells. However, there was no synergistic increase in mucin gene expression, with the exception of MUC4 mRNA expression stimulated by 25 microg/mL Aspergillus. When RV-16-infected epithelial cells were stimulated with fungi and then co-cultured with eosinophils, MUC4, MUC5B, and MUC8 mRNA expressions increased. Mucin gene expression was inhibited by NF-kappaB inhibitors. CONCLUSIONS: RV-16, airborne fungi, and eosinophils may exacerbate the inflammatory process in nasal mucosal diseases by enhancing mucin gene expression.

Comparison of the Tuberculin Skin Test and the Interferon-gamma Release Assay for the Diagnosis of Cervical Tuberculous Lymphadenitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To compare the tuberculin skin test (TST) and the interferon gamma release assay (IGRA) for the diagnosis of cervical tuberculous lymphadenitis (TL). SUBJECTS AND METHOD: A prospective comparison between the TST and the IGRA was performed in subjects who met the inclusion criteria for suspicious cervical TL. TL was confirmed by culture results and clinical diagnosis of TL was also made by histology, polymerase chain reaction and treatment response of the anti-tuberculosis drug. RESULTS: Of the 43 subjects enrolled, 11 subjects were confirmed as TL, nine subjects as clinical TL and 23 subjects as non-TL. The TST and the IGRA were all positive in TL. The agreement between the TST and IGRA was kappa=0.40 in both clinical TL and non-TL. The sensitivity and specificity of the TST were 95.0% [95% confidence interval (CI), 92.1-97.9] and 39.1% (95% CI, 32.6-45.6), respectively. By comparison, the sensitivity and specificity of the IGRA were 85.0% (95% CI, 80.3-89.8) and 52.2% (95% CI, 45.5-58.8), respectively. CONCLUSION: The IGRA was more specific than the TST, while the TST was more sensitive than the IGRA. The higher specificity of IGRA could make IGRA play a useful adjunct role in the diagnosis for cervical TL.