Correlation of Upper Lateral Cartilage Collapse and Nasal Septal Deviation

Background and Objectives@#This study aimed to elucidate the relationship between nasal septal deviation (NSD) and upper lateral cartilage (ULC) collapse. @*Methods@#We conducted a retrospective review of 142 paranasal sinus computed tomography scans from patients who had undergone septoplasty due to confirmed NSD. The ULC angle was measured on both the narrow and wide sides of the nasal cavities, and these measurements were compared to evaluate the extent of ULC collapse in relation to the degree of NSD and patient age. The correlation between the degree of NSD and the degree of ULC collapse was also analyzed. @*Results@#The mean ULC angle was found to be 13.4°±2.7° on the narrow side and 14.3°±2.7° on the wide side, with a statistically significant difference between the two (p<0.001). When comparing caudal and non-caudal NSD patients, there was no significant difference in the degree of ULC on either side (p=0.166). When comparing the ULC angle between two age groups (≥50 vs. <50 years), the difference in ULC angles was significantly greater in the group of patients aged under 50 years (0.3°±3.8° vs. 1.1°±2.2°, p=0.014). There was a significant positive correlation between the degree of ULC collapse and the degree of septal deviation (r=0.214, p=0.01). @*Conclusion@#NSD was associated with ULC collapse on the narrow side and a narrow internal nasal valve area. This result indicates that clinicians should check for concomitant ULC collapse in patients with NSD.

Iatrogenic Skull Base Defect Accompanied by Brain Injury After Endoscopic Sinus Surgery: A Report of Two Cases

Although iatrogenic skull base injuries after endoscopic sinus surgery (ESS) are rare (overall complication rate, 0.5%), they can be fatal or cause significant morbidity. Conventionally, skull base injuries were repaired using an external approach. However, in recent years, most skull base injuries after ESS have been repaired using an endoscopic transnasal approach due to its lower morbidity, lower risk of postoperative complications, and shorter hospital stay. We report two cases of iatrogenic skull base injury accompanied by brain injury following ESS and describe the skull base repair techniques employed for each case. In both cases, the skull base defects were successfully repaired using an endoscopic transnasal approach, although craniotomy was also performed in the first case to remove bone fragments from the right frontal base and lateral ventricle. Both patients recovered without residual neurologic deficits.

Resection Via Transpalatal Approach of Huge Solitary Fibrous Tumor Involving Pterygopalatine Fossa / 대한이비인후과학회지

Solitary fibrous tumors (SFTs) are spindle-cell tumors that rarely arise within extrathoracic area. Massive SFTs involving the pterygopalatine fossa are extremely rare and surgical excision represents a multidisciplinary surgical challenge. We present a case of 64-year-old female with a huge mass originating from the pterygopalatine fossa invading the skull base. Distinct microscopic findings and a positive nuclear staining of signal transducer and activator of transcription 6 (STAT-6) pathologically confirmed SFT. The right internal maxillary artery branch was embolized preoperatively and a surgical excision was performed through a combined technique of transpalatal, mid-facial degloving and endoscopic approach. Postoperative radiotherapy successfully removed the remnant tumor adjacent to the carvenous sinus. Follow- up MR images showed no evidence of recurrence for two years. To our knowledge, there has been no previous report of the successful treatment of this vast extent of SFT in the pterygopalatine region via endoscopic-external-combined approach and radiotherapy.

Surgical Algorithm for Obstructive Sleep Apnea: An Update

Sleep surgery is part of a continuum of care for obstructive sleep apnea (OSA) that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as positive airway pressure or oral appliance therapy. The updated surgical algorithm in this review adds precision in three areas: patient selection, identification of previously unaddressed anatomic phenotypes with associated treatment modality, and improved techniques of previously established procedures. While the original Riley and Powell phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.

Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea

There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.

Application of Machine Learning in Rhinology: A State of the Art Review / 대한이비인후과학회지

The revolutionary development of artificial intelligence (AI) such as machine learning and deep learning have been one of the most important technology in many parts of industry, and also enhance huge changes in health care. The big data obtained from electrical medical records and digitalized images accelerated the application of AI technologies in medical fields. Machine learning techniques can deal with the complexity of big data which is difficult to apply traditional statistics. Recently, the deep learning techniques including convolutional neural network have been considered as a promising machine learning technique in medical imaging applications. In the era of precision medicine, otolaryngologists need to understand the potentialities, pitfalls and limitations of AI technology, and try to find opportunities to collaborate with data scientists. This article briefly introduce the basic concepts of machine learning and its techniques, and reviewed the current works on machine learning applications in the field of otolaryngology and rhinology.

Radiofrequency Diathermy for Rhinogenic Headache / 대한이비인후과학회지

Rhinogenic headache is a headache or facial pain syndrome secondary to mucosal contact points or rhinogenic causes in the absence of rhinitis/sinusitis. The authors report a case of atypical rhinogenic headache in a 72-year-old woman who presented with recurrent right side headache, which was aggravated by nasal breathing. A computed tomographic scan showed no evidence of rhinosinusitis and mucosal contact points. However, during nasal endoscopy, she had multiple pain-trigger points on the septum and lateral nasal wall. Treatment involved endoscopic reduction and radiofrequency diathermy of the pain-trigger point. Postoperatively, the headache was successfully relieved, and there was no evidence of recurrence. In this article, the authors present surgical option for the treatment of atypical rhinogenic headache.

Prevention Technique Using Inferior Turbinate Mucosal Flap for Septal Perforation after Septoplasty

BACKGROUND AND OBJECTIVES: Septal surgery is the most common cause of nasal septal perforation. The aims of this study are to introduce a new technique for the prevention of septal perforation during septal surgery by installingan inferior turbinate mucosal flap on the injured mucosal surface, and to determine its usefulness by evaluating the treatment outcomes. MATERIALS AND METHODS: Between March 2012 and March 2013, 90 cases of conventional septoplasty were performed. Bilateral mucoperichondrial tears on corresponding areas occurred in 4 cases. Autologous cartilage was inserted and then both sides were repaired using inferior turbinate mucosal flaps. Follow-up periods ranged from 5 to 6 months. RESULTS: Three of the four patients had successful outcomes with complete repair of injuries. The remaining patient had a septal perforation. CONCLUSIONS: The technique of using an inferior turbinate mucosal flap may be an easy, effective method for the prevention of septal perforation during septal surgery.

Primary Burkitt's Lymphoma in the Nasal Cavity and Paranasal Sinuses

Burkitt's lymphoma is a highly aggressive small B-cell lymphoma. The treatment of choice is complex chemotherapy. As a rare tumor in the head and neck area, Burkitt's lymphoma usually involves cervical lymph nodes, and only fewer than 25% of cases involves extranodal regions. Involvement of the paranasal sinuses has been reported in only 14 cases in the past century. We describe here two patients with rare, sporadic, American type Burkitt's lymphoma involving the nasal cavity and paranasal sinuses manifesting nasal obstruction. We also review clinical and histological features of Burkitt's lymphoma.

Bilateral Pneumosinus Dilatans of the Maxillary Sinuses with Facial Pain / 대한이비인후과학회지

Pneumosinus dilatans is a rare disease in which 1 or more paranasal sinuses are dilated without functional alteration. The frontal sinus is the most commonly affected site, with involvement of the maxillary sinus being rare. A 25-year-old man had complained of facial pain and headache of frontal area. These symptoms were aggravated after nose blowing. A computed tomographic scan showed a hyperaeration of both maxillary sinus and frontal sinus. We treated the condition by endoscopic sinus surgery (middle meatal antrostomy, both). Just after operation, facial pain and headache of frontal sinus have subsided. No recurrence was detected. In this article, the authors present surgical options for the treatment of pneumosinus dilatans of the maxillary sinus, including a review of the literature.

Penetrating Neck Laceation with Epiglottis Amputation Which Was Successfully Repaired / 대한이비인후과학회지

Penetrating traumatic laryngeal injuries are relatively rare and traumatic injuries to the epiglottis are extremely rare. The present case is 58-year old man with suicidal history, chronic alcoholism, and schizophrenia who complained of neck laceration and unconsciousness after stab injury. Examination revealed a large transverse laceration of 7 cm in size, penetrating deep to the level of thyroid cartilage from the lateral border of the sternocleidomastoid muscle, exposing the thyroid cartilage. There was about a 3 cm-sized deep wound under the thyroid gland level but no major vessel injury. The stump of transected epiglottis accompanied by rupture of thyroid membrane was shown but the esophagus was intact. We sewed the amputated epiglottis with the rest of the epiglottis by using two Lambert sutures with vicryl 4-zero on each side under general anesthesia. There was no necrosis of the severed epiglottis, swallowing difficulty, and aspiration on eating food. We report here on the penetrating laceration with subtotal transection of epiglottis that was successfully repaired.

Use of Triamcinolone-Impregnated Nasal Packing Following Endoscopic Sinus Surgery

OBJECTIVES: To investigate the effectiveness of steroid-impregnated absorbable nasal dressing on wound healing and surgical outcomes after endoscopic sinus surgery (ESS). MATERIALS AND METHODS: Chronic rhinosinusitis patients with nasal polyps who were to undergo bilateral ESS were recruited and randomized to receive triamcinolone-impregnated bioresorbable dressing (Nasopore(R); Polyganics, Groningen, Netherlands) in one nasal cavity and saline-impregnated dressing contralaterally. Postoperative healing assessments of edema, crusting, secretions, and scarring were done at postoperative days 7, 14, and 21 and at 1 and 3 months using validated Lund-Kennedy scores. RESULTS: Analysis of the 20 enrolled patients who completed observation showed no significant difference in Lund-Kennedy scores between the preoperative cavity scores. There was, however, a statistically significant difference in Lund-Kennedy scores of the treatment and control groups at days 7 and 14 (P =0.005 and P=0.0039, respectively), and a significant difference in Lund-Kennedy scores was also detected between the groups at the 3-month time point (P =0.042). CONCLUSION: The results of the data analysis suggest a significant improvement in early postoperative healing and improved healing for up to 3 months postoperatively in nasal cavities receiving triamcinolone-impregnated absorbable nasal packing following ESS.

Cervicofacial Emphysema and Pneumomediastinum Following Pediatric Adenotonsillectomy

Many patients regard tonsillectomy as a minor operation because it is performed frequently. Although tonsillectomy is considered a relatively safe surgical procedure, numerous complications have been described. The common complications are hemorrhage, infection, and following anesthesia, aspiration, cardiac arrhythmia, and laryngeal trauma. Cervicofacial emphysema and pneumomediastinum are rarely observed sequelae of surgical intervention in the upper aerodigestive tract. Although these complications resolve spontaneously in most cases, a few cases result in tension pneumothorax and other life-threatening conditions. Symptoms include chest pain, neck pain, dyspnea and odynophagia. Treatment involves frequent assessment of the airway and extent of the emphysema. The authors of the present study report of a patient who developed pneumomediastinum shortly after an adenotonsillectomy as well as a review of the related literature.

Three Cases of Surgical Repair of Traumatic Parotid Duct Injury / 대한이비인후과학회지

It is important to both recognize parotid duct injuries and immediately repair them to prevent complications that accompany these injuries. Although there have been some reports of successful conservative treatments of the parotid duct injury, many authors recommend early surgical repair of the parotid duct and, when possible, primary anastomosis as the best treatment. Sialography is very useful for the diagnosis of parotid duct injury and can also support the information of parotid duct system. We present three cases of successful treatment of parotid duct injury with surgical repair. Also, we discuss about the effectiveness of surgical repair of parotid duct injury and how to assess it preoperatively.

A Case of Recurrent Osteoclastoma of the Paranasal Sinuses in a Patient with Paget's Disease / 대한이비인후과학회지

Paget's disease is a well-known disorder of unclear etiology that results in deformity and enlargement of single or multiple bones due to abnormal osteoclastic-osteoblastic remodeling of bone. Osteoclastoma, also known as giant cell tumor, is a rare complication of Paget's disease that usually occurs in the skull or facial bones. This is a report of a 35-year-old woman with recurrent osteoclastoma of the sino-nasal tract, a complication of Paget's disease, for which she underwent 4 operations. Clinicopathological features of this rare disease are described here.

Treatment Results of 111 Cases of Antrochoanal Polyp

BACKGROUND AND OBJECTIVES: Antrochoanal polyp (ACP) is a benign maxillary sinus polyp that originates from the mucosa of the maxillary sinus, passes through the sinus ostium, and extends into the choana. Surgical methods employed in the treatment of antrochoanal polyp are simple avulsion, Caldwell-Luc operation, osteoplastic maxillary sinus operation, and endonasal endoscopic removal. In this study, we evaluated the clinical presentation of ACP and compared its surgical outcomes. MATERIALS AND METHODS: We retrospectively reviewed 111 patients who were treated for ACP between January 1995 and May 2008, and analyzed clinical features, radiologic findings, and surgical results. RESULTS: The study group consisted of 111 patients (65 males, 46 females) with a mean age of 20.0 years (range, 4 to 70). Sixty-one cases were accompanied by sinusitis (20 with unilateral sinusitis, 41 with bilateral sinusitis). Endoscopic sinus surgery (ESS) was used to treat 95 cases, and the external approaches of Caldwell-Luc operation or osteoplastic maxillary sinus operation were applied in 12 and four cases, respectively. Among those who received ESS, ACP recurred in 16 cases, whereas none of the patients who received the external approach showed recurrence. CONCLUSION: Endoscopic sinus surgery is a good alternative method for the treatment of ACP. If the antral part of ACP cannot be removed completely, an external approach such as Caldwell-Luc operation or osteoplastic maxillary sinus operation for pediatric patients may be considered to prevent recurrence.

Clinical Significance of Retropharyngeal Lymph Node Metastasis from Hypopharyngeal Squamous Cell Carcinoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Little information about the incidence of retropharyngeal adenopathy and its impact on prognosis has been published. The purpose of this study is to investigate the incidence and prognostic significance of metastatic retropharyngeal adenopathy in patients with squamous cell carcinoma of the hypopharynx. SUBJECTS AND METHOD: The pretreatment CT/MRI of 121 patients with squamous cell carcinoma of the hypopharynx were reviewed for the presence of metastatic retropharyngeal lymph nodes. All patients were treated between 1996 and 2005. The influence on recurrence (local and regional), distant metastasis, and survival was retrospectively analyzed. Mean follow-up was 28.3 months. RESULTS: Retropharyngeal node involvement was present in 21 (17.4%) patients. The clinical T staging was the most significant factor relating to the incidence of retropharyngeal adenopathy in multivariate analysis (p=0.006). The rates of regional recurrence and distant metastasis were significantly higher in patients with retropharyngeal adenopathy. Disease specific survival rate was significantly lower in the retropharyngeal node positive group (p=0.013). CONCLUSION: Retropharyngeal node involvement has a negative impact on the prognosis of squamous cell carcinoma of the hypopharynx. Patients are particularly at risk for distant metastasis, resulting in worse disease-specific survival. Retropharyngeal node involvement should be taken into account in designing the treatment plan for these patients.

Clinical Characteristics and Treatment Outcomes of Endoscopic Sinus Surgery in Pediatric Chronic Rhinosinusitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Pediatric rhinosinusitis continues to be a challenging problem to otolaryngologists. This study aims to assess the clinical characteristics of chronic rhinosinusitis and the treatment outcomes of endoscopic sinus surgery (ESS) in children. SUBJECTS AND METHOD: Forty eight patients (13 women and 35 men with an age range of 7 to 17 years) were available for analysis by medical records and questionnaire. We classified the patients into three groups: 25 cases of chronic rhinosinusitis with nasal polyposis (CRSNP), 11 cases of chronic rhinosinusitis without nasal polyposis (CRS), 12 cases of antrochoanal polyps (ACP). Objective outcome of ESS was evaluated through endoscopic examination and subjective outcome through questionnaire. Postoperative follow-up period ranged between 6 and 26 months. RESULTS: Thirty-nine patients were treated with ESS and nine with ESS with concomitant adenoidectomy. Thirty-nine patients (81.2%) showed good outcomes by endoscopic examination. Also, thirty-eight patients (79.2%) reported high satisfaction by questionnaire. There were no statistical differences in the results through endoscopy and subjective satisfaction through questionnaire among three groups. CRSNP and ACP groups tended to have higher recurrence rate than CRS group. CRSNP group showed higher CT Lund-Mackay scores than ACP group and CRS group. Synechia occurred in 4 (8.3%) of 48 patients. Ten patients (20.8%) required endoscopic polypectomy or revision surgery. CONCLUSION: While pediatric ESS is still in progress and its role continues to be defined, the results of current study suggest that pediatric ESS is a safe and efficacious therapy for management of chronic rhinosinusitis in children.

Height and Shape of Skull Base as Risk Factors for Skull Base Penetration during ESS

BACKGROUND AND OBJECTIVES: CT/MRI has identified several risk factors for life threatening complications of skull base penetration during endoscopic sinus surgery (ESS). We compared these risk factors in groups of patients with and without penetration. MATERIALS AND METHODS: Retrospective review of direct coronal paranasal sinus computed tomography (CT) scans was done. Using preoperative CT scans of 100 patients without penetration, and 7 with penetration, we classified height into 4 groups and contour into 2 groups. The frequencies of shape and height differences of the right and left skull base were calculated in each group. RESULTS: 6 of the 7 patients who had skull base penetration, ESS was performed by a resident or junior staff member having less than 3 years experience with this technique. Shape asymmetry was significantly higher in with penetration (4 out of 7 patients (57%)) and much less in without penetration (18 out of 100 patients, 18%, p=0.032). The frequencies of low skull base and height difference were seen in 15% and 28%, respectively. CONCLUSION: The most important risk factor for inadvertent skull base penetration during ESS is the surgeon's experience and asymmetric shape of the right and left skull base.