Clinical Applications of Office-Based Laryngeal Surgery With KTP Laser

The pulsed photoangiolytic 532-nm potassium-titanyl-phosphate (KTP) laser has emerged in recent years as an efficacious treatment modality for vocal fold lesions. It also has broadened the indications for other laryngeal laser surgery. Features of KTP laser that it is a fiber-based delivery system and its energy is selectively absorbed by oxyhemoglobin make it suitable for office-based laryngeal procedures. An office-based KTP laser surgery provides an alternative management option for benign laryngeal diseases and can be performed comfortably under flexible endoscopic guidance which is placed through the nose of a fully awake patient. Office-based laryngeal surgery with a KTP laser can alleviate the need for general anesthesia. However, there are some limitations to apply due to reduced visual precision and the fact that the vocal folds are moving during procedures. Clinicians should carefully weigh the advantages and disadvantages of office-based procedures before a treatment option is selected. Patient selection and standardized laser energy parameters may help in decreasing complications and improving the treatment results.

The Korean Dysphagia Society (KDS) Position Statement for Oropharyngeal Dysphagia / 대한연하장애학회지

Oropharyngeal dysphagia is a clinical condition caused by various underlying diseases and is characterized by difficulty in swallowing. Diagnosis and treatment of oropharyngeal dysphagia require multidisciplinary consultations. This position statement for oropharyngeal dysphagia was developed by The Korean Dysphagia Society (KDS) to outline its position on oropharyngeal dysphagia. The clinical practice guideline, position statements, a recent meta-analysis, a systematic review, and randomized controlled trials for oropharyngeal dysphagia were all performed. An expert Delphi survey was also done to achieve a consensus of opinion on this position statement. This position statement for oropharyngeal dysphagia aims to help make evidence-based decisions in clinical practice, improve clinical evaluation and manage oropharyngeal dysphagia in Korea.

Clinical Applications of Botulinum Toxin in Patients with Dysphagia

Dysphagia may result from dysfunction of any of the components involved in the complex neuromuscular interaction of swallowing. Hyperfunction of any of the muscles involved in swallowing is a frequent cause of dysphagia. The cricopharyngeus muscle (CPM) is a key component of the upper esophageal sphincter. Cricopharyngeus muscle dysfunction (CPD) refers to the muscle's failure to appropriately and completely relax or expand during deglutition. A variety of disease processes may cause CPD and accurate diagnosis is paramount for appropriate treatment. In appropriately selected patients, intervention at the CPM may yield significant improvement in dysphagia. Interventions include nonsurgical, pharyngoesophageal segment dilatation, botulinum toxin (BoNT) injection, and criccopharyngeal myotomy. Injections of BoNT in patients with CPD have been reported to result in marked relief of dysphagia. Different techniques for instilling BoNT into the CPM have been described. Awake, in-office CPM BoNT injection with electromyography and/or fluoroscopic or ultrasound guidance is performed transcervically or via flexible endoscopy. Operative CPM BoNT injection involves rigid laryngoscopy and esophagoscopy with direct visualization of the CPM. BoNT should be prepared in low-volume, high-concentration dilutions to minimize the potential for undesired diffusion of the toxin. The effects of BoNT occur within weeks of injection and typically last up to 5 or 6 months.

A Case of Unilateral Vocal Fold Paralysis Secondary to Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Vocal fold paralysis secondary to sarcoidosis is extremely rare but it can develop as a result of compressive lymphadenopathy, granulomatous infiltration, and neural involvement. We report the case of a 56-year-old woman who presented with unilateral vocal fold paralysis and enlarged supraclavicular lymph nodes. Computed tomography of the neck revealed multiple, enlarged, and matted lymph nodes at the cervical level of IV. An ultrasound-guided core needle biopsy of the lymph node was performed, and a histopathological diagnosis of sarcoidosis was made by validating the presence of noncaseating granuloma. After implementation of steroid therapy, the patient exhibited immediate recovery from vocal fold paralysis. Although an extremely rare disease, sarcoidosis should be included in the differential diagnosis of vocal fold paralysis. Accurate diagnosis and prompt steroid treatment may reduce the morbidity of patients with vocal fold paralysis secondary to sarcoidosis.

A Case of Solitary Neurofibroma Arising from Cervical Vagus Nerve in Pregnant Woman / 대한이비인후과학회지

Neurofibromas are benign tumors of the peripheral nerve sheath, which occur as either a solitary mass or multiple tumors in association with neurofibromatosis. Solitary vagal neurofibroma in the cervical region is very rare among neurogenic tumors. Unlike schwannomas, neurofibromas have been known to express progesterone receptor and tend to fluctuate during periods of hormonal imbalance. We report a case of a 27-year-old pregnant woman who presented with neck swelling with tenderness. The mass was more enlarged during the gestational period, and she underwent neck surgery after giving birth. At surgery, the mass was found to be originating from the cervical vagus nerve. We exerted to preserve the continuity of vagus nerve during tumor resection. Pathological examination revealed a neurofibroma. It occurred sporadically, not associated with neurofibromatosis. We should be informed that neurofibroma in pregnant woman may be more rapidly enlarged due to pregnancy-associated hormones such as progesterone.

A Case of Systemic Lupus Erythematosus Involved Central Nervous System Presenting as Acute Sialoadenitis / 대한이비인후과학회지

Systemic lupus erythematosus (SLE) is a multi organ-involving systemic disease and usually manifests as musculoskeletal and cutaneous presentation. Acute sialoadenitis in lupus patients is not a typical manifestation. We report the case of a 23-year-old woman who presented with both parotid and submandibular gland painful swelling with highly elevated level of serum amylase. Epileptic seizure unexpectedly occurred during conservative treatment of the mentioned disease. After a close examination for the systemic or underlying disease, SLE was detected by specific autoantibody. The patient was uneventfully discharged after steroid pulse therapy. Although it is a very rare manifestation, autoimmune disease such as SLE should be included in differential diagnosis, especially in young women, when acute sialoadenitis is not improved with conservative management.

A Case of Trichilemmal Cyst Invading Submandibular Gland / 대한이비인후과학회지

A trichilemmal cyst is a skin adnexal tumor that usually occurs on the scalps of elderly women. We report a trichilemmal cyst in the submandibular area of a 16-year-old male, masquerading as a second branchial cleft cyst. During surgery, the mass was found to have invaded the submandibular gland and needed to be excised totally in continuity with the submandibular gland. To our knowledge, this is the first reported case of a trichilemmal cyst involving the submandibular gland. Although rare, a trichilemmal cyst may be considered in the differential diagnosis of cystic lesions in the submandibular area. It should also be differentiated from other cystic malignant tumors for its tendency to invade the surrounding structure.

A Case of Small Cell Carcinoma of the Maxillary Sinus with Distant Metastasis / 대한내과학회지

Primary small cell carcinoma of the paranasal sinuses is extremely rare. It is aggressively locally invasive, with high recurrence and metastatic rates. A combination of systemic chemotherapy and locoregional treatment, such as radiotherapy, is currently recommended based on the treatment of small cell carcinoma of lung. We report a case of small cell carcinoma originating from the maxillary sinus with distant metastasis at the time of diagnosis. The patient had a good initial therapeutic response to etoposide-cisplatin chemotherapy, but the cancer progressed after the sixth cycle of chemotherapy and the prognosis was poor.

A Case of Amyloid Goiter Masquerading as Graves' Disease

Amyloidosis is an abnormal extracellular deposit of amyloid in various organs of the body. Amyloid goiter, defined by a clinically detectable thyroid enlargement due to amyloid deposition, is a rare cause of hyperthyroidism. We report the case of amyloid goiter mimicking Graves' disease in a 62-year-old woman. Graves' disease was diagnosed by diffuse goiter, hyperthyroidism, and positive TSH receptor antibody. Total thyroidectomy was planned due to progression of Graves' disease and respiratory distress. At surgery thyroid gland was very friable and fragmented like cobblestones when grasped with forceps. A diagnosis of amyloid goiter was established by the presence of diffuse amyloid deposits in the parafollicular areas. After systemic evaluation for amyloidosis, coexisting both multiple myeloma and systemic amyloidosis involving kidney and heart were detected. She underwent palliative chemotherapy but disease progressed. Amyloid goiter might be suspected in patient with thyroid enlargement and concomitant systemic disease such as renal or heart failure.

A Case of Primary Papillary Thyroid Cancer That Caused Vocal Cord Palsy Arising from Thyroid Rest

Thyroid rest is isolated deposit of normal thyroid tissue arising in the thyrothymic tract below the lower pole of thyroid gland. Malignant transformation of thyroid rest is very rare. We report an extremely rare case of papillary carcinoma arising from thyroid rest in a 56-year-old male. He presented with hoarseness due to vocal cord palsy. Paratracheal mass in the upper mediastinum was identified by the cause of vocal cord palsy on CT. During surgery, we identified that the mass invaded recurrent laryngeal nerve but had no connection to thyroid gland. Histopathologic examination revealed that the mass was primary papillary thyroid carcinoma and there was no evidence of malignancy in thyroid gland. The post-therapeutic I-131 whole body scan detected several focal hot uptake in lung and mediastinum, suggesting distant metastasis. We should have knowledge of developmental variations of thyroid gland such as thyroid rest and its malignant transformation.

A Case of Eagle's Syndrome after Blunt Neck Trauma / 대한이비인후과학회지

Eagle's syndrome has various symptoms at cervico-facial lesion. Recently, we have experienced a case of Eagle's syndrome that developed after a blunt neck trauma. A 51-year-old man presented with a click sound when he turned his head to the right. The symptom had developed after a traffic accident that occurred 2 months ago. Physical examination revealed a long styloid process that was easily palpable and burging out into the right tonsillar fossa. Radiologic examination did not reveal any presence of fracture on stylohyoid complex including stylohyoid ligament. We underwent a transoral resection of styloid process and released a stylohyoid ligament. The patient immediately experienced a relief of the symptom following the operation. It might be elucidated that the patient had an elongated styloid process and that the neck trauma had developed due to the dislocation or pseudoarticulation between stylohyoid ligament and the hyoid bone. Transoral resection of styloid process released pseudoarticulation and relieved the symptom.

Multiple Cervical Schwannomas Mimicking Metastatic Lymph Nodes from Papillary Thyroid Cancer / 대한갑상선학회지

We report a case of multiple cervical schwannomas mimicking cervical nodal metastasis in a 45-year-old female patient with papillary thyroid carcinoma. Ultrasonography revealed a hypoechoic lesion with irregular contour in the left isthmus of the thyroid gland. A contrast-enhanced CT of the neck showed two well-circumscribed, cystic masses in the left cervical level II. The preoperative results of ultrasonography guided fine needle aspiration biopsy from both thyroid and lateral neck masses were papillary thyroid cancer and atypical cell, respectively. Considering clinical and imaging results, the lateral neck masses were suspected to be metastatic cervical lymphadenopathy. During surgery, however, we identified that two lateral neck masses were originated from spinal accessory nerve and cervical plexus. The pathologic examination confirmed that lateral neck masses were typical schwannomas. Before surgery, it is important to make every efforts to discriminate metastatic lymphadenopathy from the cystic neck mass in patients with papillary carcinoma.

A Hypopharyngeal Ductal Cyst Masquerading as a Laryngopharyngeal Reflux Disease

The ductal cyst of the hypopharynx is a very rare tumor. We report a case of hypopharyngeal ductal cyst in a 63-year-old man presenting with globus sensation. It was removed by a laryngomicrosurgical technique, using a microdissection electrode. Masses of the hypopharynx may not always be easily visible on routine examination of the hypopharynx with flexible fiberoptic laryngoscopes. Particularly in cases of benign tumors, the diagnosis may be delayed due to a prolonged history of mild and subtle symptoms. We missed the hypopharyngeal mass at the initial presentation, but could detect the mass in the pyriform sinus with a double contrast barium swallow study. We describe the diagnostic method to detect hypopharyngeal tumors and the treatment of benign hypopharyngeal masses.

Venous Hemangioma of Parapharyngeal Space with Calcification

A hemangioma of the parapharyngeal space (PPS) is an extremely rare tumor and is responsible for 0.5-1% of all tumors occurring in the PPS. We report a case of PPS venous hemangioma in a 49-year-old woman presenting with diffuse swelling in the submandibular region. A preoperative computed tomography (CT) scan showed a cystic mass with multiple calcifications in the PPS. The calcific nodules were round and about 2 mm in diameter. The hemangioma was completely resected via a transcervical approach. During surgery, we found several calcific nodules, which represented phleoboliths or areas of thrombosis with dystrophic calcification. Despite its rarity, a venous hemangioma of the PPS should be considered in a differential diagnosis when a cystic mass with calcification is found by CT scan. To our knowledge, this is the first reported case of a PPS venous hemangioma; we describe its pathognomonic findings on imaging.

A Case of Hypoglossal Nerve Palsy after Tonsillectomy / 대한이비인후과학회지

Tonsillectomy is a common procedure in the ENT department but unusual complications related to nerve injury might be associated with the surgery. We report a case of permanent hypoglossal nerve palsy following tonsillectomy in a 33-year-old female patient. The findings from the neurologic examination were unremarkable except for tongue deviation to the left, hemiatrophy of the tongue and associated dysarthria. Forceful pressure and stretch of hypoglossal nerve during surgery can explain the cause of injury. To avoid nerve compression, intermittent release of the mouth gag and avoidance of neck hyperextension are suggested especially when long operation time would be expected. Although rare, having knowledge of the existence of hypoglossal nerve injury complicating tonsillectomy is important when counseling patients.

Rehabilitation Protocol for Postoperative Dysphagia in Head and Neck Cancer Patients / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Treatment of head and neck cancer patients with surgical removal may result in some degree of dysphagia. Swallowing disorders depend on the site, the extent of surgical resection, and the nature of the surgical reconstruction. As a result, rehabilitation needs to be managed by head and neck surgeons with specific anatomical knowledge. However, in Korea, only occupational therapists can get approval for dysphagia rehabilitation from the national health insurance cooperation. Therefore, we designed a Advanced Rehabilitation Protocol (ARP) rehabilitation and carried out a comparative study against the current rehabilitation protocol. SUBJECTS AND METHOD: Data were collected by reviewing medical records of 40 patients who received operation on oral cavity, larynx and hypopharynx from November 2007 to January 2009. Of these, 20 patients were treated with ARP under the management of head and neck surgeons but the other 20 patients were not. RESULTS: Although the results had no statistical significance, the study showed that ARP had the effect of shortening the rehabilitation and enabled them to start adjuvant therapies early. CONCLUSION: Rehabilitation needs to be managed cooperatively by a multidisciplinary team that includes an otolaryngologist who has specific anatomical knowledge of the concerned area and reconstruction according to specific swallowing problems.

Patterns and Clinical Significance of Nodal Metastasis in Squamous Cell Carcinoma of Hypopharynx / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate the incidence and prognostic significance of cervical lymph node metastasis in squamous cell carcinoma (SCC) of the hypopharynx. SUBJECTS AND METHOD: A retrospective review of the 64 patients who were previously untreated for SCC of the hypopharynx and underwent surgery was performed from October 1993 to June 2008. Fifty-six patients had simultaneous bilateral neck dissection, whereas eight had unilateral neck dissection. RESULTS: The median age was 61.0 years (range, 34-75 years) for the study group consisting of 62 males and two females. Evaluating according to the N stages, there were 15 (23.4%), 10 (15.6%), 37 (57.8%), and 2 (3.1%) cases with N0, N1, N2 and N3, respectively. Forty-nine patients (76.6%) had pathologically proven cervical metastasis. Contralateral occult lymph node metastasis occurred in 20.5%. Ipsilateral and contralateral occult metastasis rates for clinically node negative patients were 41.2% and 11.8%, respectively. The most frequent sites for positive neck nodes occuring at each level were as follows: II (48.5%), level III (40.6%), level IV (26.6%), paratracheal node (21.4%), level V (9.4%), levels I (7.8%), and retropharyngeal node (6.3%). The 5-year overall survival and disease-specific survival rates were 50% and 53%, respectively. Cervical nodal metastasis (p=0.044) was statistically significant prognostic factors for disease-specific survival. CONCLUSION: Metastasis to the cervical lymph node group is very frequent and has an impact on survival in patients with hypopharyngeal SCC. Therefore, we advocate bilateral neck dissection in patients with hypopharyngeal SCC with clinically positive metastasis. Ipsilateral elective neck dissection may be needed for clinically node negative patients.

A Case of Warthin's Tumor Associated with Primary Tuberculosis of the Parotid Gland in a Patient with Acquired Immunodeficiency Syndrome / 대한이비인후과학회지

Parotid gland is an uncommon location for tuberculosis, but the incidence in this lesion has increased in human immunodeficiency virus (HIV) infection. Warthin's tumor is a relatively common benign tumor of the salivary glands. However, a coincidence of tuberculosis and Warthin's tumor in the parotid gland is extremely rare. We report a case of a patient with acquired immunodeficiency syndrome (AIDS) who presented parotid swelling. After superficial parotidectomy, the lesion was diagnosed to be tuberculosis associated with Warthin's tumor.

Analysis of Influencing Factors on Cervical Lymph Node Metastasis in Early Oral Tongue Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The status of cervical lymph node metastasis has a greatinfluence on the prognosis of patients with early oral tongue cancer. We evaluated various clinical, histopathological, lymphangiogenic parameters and their association with cervical lymph node metastasis in early oral squamous cell carcinoma of the tongue. SUBJECTS AND METHOD: Fifty-one patients with squamous cell carcinoma of the early oral tongue were classified as their tumor stage, lymph node metastasis, histopathological grade, tumor depth of invasion and their paraffin-embedded surgical specimens were investigated by immunohistochemical analysis using VEGF and E-cadherin antibody. RESULTS: Cervical lymph node metastases were present in 18 of the 51 cases (35.3%). Regarding tumor cell differentiation, there were 28 (54.9%), 19 (37.3%), and 4 (7.8%) well-, moderate-, and poorly-differentiated cases, respectively. The depth of invasion varied from 1 to 25 mm and averaged 9.69+/-5.83 mm, and there was a significant correlation between the tumor depth ofinvasion and cervical lymph node metastasis (p<0.001) and primary tumor size (p<0.001). Immunohistochemical analysis showed the expression rates of VEGF, E-cadherin as 46.9% and 52.9%, respectively. There was significant correlation between the expressions of VEGF and lymph node metastasis (p=0.009). Patients who were followed up for more than 12 months had a 5-year overall survival of 82%. Primary tumor size and VEGF expression was associated with the overall survival. CONCLUSION: The analysis of these clinical, histological, and immunohistochemical parameters may help to identify patients who would benefit from a neck dissection by predicting the likelihood of cervical lymph node metastasis.

Spindle Cell Lipoma Involving the Larynx and Lateral Neck Space

Spindle cell lipoma (SCL) is a rare lipoma variant that account for approximately 1.5% of all adipocyte-origin tumors; SCL usually occurs on the posterior neck or shoulder. The histological characteristics of SCL include mature, univacuolar fat cells and fibroblast-like spindle cells in a matrix of collagen and mucoid material. It is important to note that spindle cell lipoma can be mistaken both clinically and histologically for liposarcoma. We report here on a rare case of SCL in a 48-year-old male, and the patient presented with a large right neck mass that involved the lateral neck space and larynx.