Endoscopic Trans-Turbinal Medial Maxillectomy: A Modified Endoscopic Medial Maxillectomy Technique to Preserve the Inferior Turbinate / 대한이비인후과학회지

Endoscopic medial maxillectomy (EMM) and its modifications are surgical techniques are used to treat recalcitrant maxillary sinusitis as well as maxillary sinus tumors. In this report, we propose a simple and efficient modification of EMM, called endoscopic trans-turbinal medial maxillectomy (ETTMM), by which the inferior turbinate (IT), nasolacrimal duct, and anatomical integrity of the nasal valve area are preserved. A total of 10 patients (five tumorous and five nontumorous maxillary diseases) underwent ETTMM. Briefly, a turbinate mucosal flap on the superior aspect of the IT was elevated after middle meatal antrostomy. Then a trans-turbinal window was developed to expose the inferior meatus, after which an extended maxillary antrostomy was generated. Finally, the turbinate mucosal flap was repositioned after complete removal of the antral lesions. All lesions were successfully treated using ETTMM. Our modification was easy to perform, and we achieved good endoscopic visualization and accessibility throughout the whole antrum by creating a trans-turbinal window and extended maxillary antrostomy. We could perform postoperative surveillance easily through the wide antrostomy using rigid endoscopes of various angles. ETTMM is a simple and useful modification of EMM that provides clear visualization and great accessibility to most aspects of the maxillary antrum while preserving the nasal functional units, including the IT and nasal valve area.

Widespread Inverted Papilloma in the Frontal Sinus Treated by Unilateral Osteoplastic Flap Surgery without Obliteration / 대한이비인후과학회지

Inverted papilloma is a rare sinonasal tumor that mainly occurs in adults during the 5th decade. Three characteristics make this tumor very different from other sinonasal tumors: a relatively strong potential for local destruction, high rate of recurrence, and a risk of carcinomatous evolution. Etiology remains little understood, but an association with human papilloma virus has been reported in up to 40% of cases, raising the suspicions of implication in the pathogenesis of inverted papilloma. Treatment of choice is surgery, by endonasal endoscopic or external approach, depending on extension and tumoral characteristics. We experienced a case of 42-year-old male with inverted papilloma which originated from the ethmoid roof and spread into the frontal sinus. He was treated successfully by unilateral osteoplastic flap surgery without obliteration, and we report on the treatment of this case, along with a review of literature.

Posterior Epistaxis: Risk Factors and Causes of Recurrence after Sphenopalatine Artery Ligation / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Most cases of epistaxis can be controlled by conservative management such electrocautery or nasal packing. However, for some cases of the posterior epistaxis, invasive procedures like endoscopic sphenopalatine artery ligation (SPAL) or arterial embolization are needed. In this study, risk factors present in patients who were hospitalized due to posterior epistaxis and postoperative complications and causes of recurrence after SPAL were analyzed. SUBJECTS AND METHOD: A retrospective chart review of 75 patients who were admitted to Gyeongsang National University Hospital for the treatment of posterior epistaxis between 2009 and 2014 was performed. Demographic factors, seasonal variation, comorbid diseases, and laboratory results were analyzed. Furthermore, 35 patients who have undergone SPAL were surveyed by telephone regarding postoperative complications, and preoperative computerized tomography (CT) images were reviewed to figure out the causes of the recurrence after SPAL. RESULTS: Among 75 patients, 53 (70.7%) were males. Male preponderance (80%) was more definite among those who have undergone SPAL (p=0.04). Age over 40 as well as the winter season and the underlying disease such as hypertension were also critical risk factors for posterior epistaxis. Four out of 35 patients who had undergone SPAL showed recurrence. The bleeding was detected in the branches of sphenopalatine artery in three out of the four patients who experienced recurrent bleeding following SPAL, which were controlled by revision surgery or arterial embolization. CONCLUSION: Posterior epistaxis occurred frequently in men over 40 years of age and in winter. A careful preoperative review of CT images and meticulous dissection during SPAL might be helpful for preventing recurrence after SPAL.

A Case of Severe Epistaxis during Pregnancy Treated by Sphenopalatine Artery Ligation / 대한이비인후과학회지

Epistaxis is a common disease encountrered in Otorhinolaryngology; however, life-threatening epistaxis during pregnancy is rare, and there are no specific guidelines regarding the management of such patients. We encountered a 38-year-old female patient in the second trimester of her pregnancy, who presented with nosebleeds. No definite focus of bleeding was identified by nasal endoscopy, thus several conservative measures were used to stop nosebleeds including bed rest with head elevation, ice pack application, and nasal packing. Despite such treatments, nosebleeding continued. Endoscopic sphenopalatine artery ligation was conducted under general anesthesia and the results were successful. In obstetric assessment, there was no evidence of fetal distress. The patient delivered a healthy baby at 40 weeks, and there was no recurrence of epistaxis through postoperative 18 months.

A Case of Small Cell Carcinoma of the Maxillary Sinus Coexisting with Fungus Ball

Small cell carcinoma commonly originates in the lung, with only about 4% of cases arising at extrapulmonary sites. Furthermore, small cell carcinoma of the sinonasal tract is extremely rare. In Korea, only 2 cases of primary sinonasal small cell carcinoma have been reported in the nasal cavity and the nasal septum, respectively. Recently, we have experienced a rare case of small cell carcinoma arising from the right maxillary sinus coexisting with a fungal ball lesion. Herein, we report this case with a review of the literature.

Development and Utilization of a Mouse Model of Nasal Polyps

Systemic corticosteroids currently represent the most effective treatment for chronic rhinosinusitis with nasal polyps (CRSwNP), but their long-term use is constrained due to their detrimental side effects. Until recently, development of novel drugs for CRSwNP has been difficult partly due to the absence of a standard animal model of CRSwNP. Exotoxins of Staphylococcus aureus such as staphylococcal enterotoxin B (SEB), are well-known superantigens which can induce a strong immune response; there have been many studies on the association of staphylococcal enterotoxins and development of CRSwNP over the past two decades. Based on previous studies, we invented a mouse model of CRSwNP using SEB. Herein, we explain the protocol development for the mouse model, as well as identify histological and immunological similarities between this mouse model and humans. Furthermore, we describe a study that analyzed the risk factors for CRSwNP such as smoking, and also elaborate on a series of studies that searched for new potential drugs for CRSwNP, including resveratrol, anti-periostin antibody, topical hypoxia-inducible factors, and topical cyclosporine. Based on preceding studies, we have concluded that this mouse model might be a useful tool to investigate the pathophysiology and development of novel drugs for CRSwNP.

Postoperative Olfactory Results in Chronic Rhinosinusitis with Nasal Polyposis According to Wound Healing Status

OBJECTIVES: Postoperative wound healing status has not been considered in earlier studies on olfactory changes after surgery. This may be a factor accounting for the equivocal postoperative olfactory results. The aim of this study was to investigate postoperative olfactory results according to wound healing status. METHODS: Fifty patients who underwent endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps with smelling disturbance were examined preoperatively, and at 6 months after surgery. Patients were divided into two groups according to postoperative Lund-Kennedy score: favorable and unfavorable wound healing. Preoperative ostiomeatal unit computed tomography (CT), such as Lund-Mackay score and olfactory cleft opacification score, clinical characteristics and olfactory function tests such as the butanol threshold test and cross-cultural smell identification test, and questionnaire responses were compared between the two groups. RESULTS: There were no differences in preoperative clinical characteristics between the favorable and unfavorable wound healing groups. The favorable wound healing group displayed greater improvement of olfactory results after surgery than the unfavorable wound healing group. Postoperative olfactory improvement patterns showed a hierarchy from subjective to objective improvement and from threshold to identification improvement. Patients who had postoperative favorable wound healing but showed no success of olfaction were characterized by more severe preoperative subjective symptoms and higher olfactory cleft opacification, especially in the upper part of olfactory cleft on preoperative CT scan. CONCLUSION: Wound healing status is an apparent risk factor for postoperative olfactory improvement. Moreover, preoperative opacification in the olfactory cleft may predict bad olfactory results after surgery, even in patients with favorable wound healing.

Ethmoidal Mucocele Presenting as Oculomotor Nerve Paralysis

A 56-year-old male was admitted with an acute headache and sudden ptosis on the right side. No ophthalmological or neurological etiologies were apparent. A mucocele of the right posterior ethmoid sinus was observed with radiology. After the marsupialization of the mucocele via a transnasal endoscopic approach, the patient's symptoms (oculomotor nerve paralysis and headache) resolved in 4 weeks. Oculomotor paralysis is a rare symptom of an ethmoidal mucocele. In this article, we report this rare case along with a literature review.

Clinical Results of Endoscopic Endonasal Transsphenoidal Hypophysectomy during an Acceleration Phase of Learning Curve / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to compare endoscopic endonasal transsphenoidal hypophysectomy (EETSA) with microscopic transseptal transsphenoidal hypophysectomy (MTTSA) in terms of clinical results during an acceleration of learning curve. SUBJECTS AND METHOD: A retrospective chart review was performed of the first 14 cases of EETSA and previous 14 cases of MTTSA. Resection results, endocrinologic outcomes, complication rates, operating time, and duration of hospital stay were investigated. A non-parametric analysis was performed to determine the significance of differences between groups. RESULTS: EETSA was performed, achieving gross total removal, based on postoperative MRI, for 12 of the 14 patients (86%) and hormonal remission for 4 of the 5 patients (80%); on the other hand, MTTSA was performed, achieving gross total removal for 9 of the 14 patients (64%) and hormonal remission for 1 of the 5 patients (20%). We found better resection results in patients who underwent EETSA than in those who did MTTSA with respect to tumors extending into suprasellar area (p<0.05). Visual improvement was achieved in all the cases with visual defect (n=5) after EETSA, whereas 4 of 6 cases (66%) were improved after MTTSA. Significant differences in complication rates, operating time and hospital stay could not be determined. All cases with CSF leakage in EETSA were successfully managed by using the nasoseptal flap. CONCLUSION: EETSA provided better resection results than MTTSA did, especially in cases extending into the suprasellar area, showing good hormonal cure and visual improvement rates. Two approaches were comparable with respect to complications during the learning curve.

Quantitative Analysis of Myosin Heavy Chain Expression Change in Laryngeal Muscle after Irradiation in Rats

PURPOSE: Radiotherapy for head and neck cancer does not impair the voice quality as much as laser treatment or surgery, but it can induce muscle wasting and fibrosis and symptoms of dry mouth. We investigated the effect of irradiation on the myosin heavy chain (MyHC) expression in laryngeal muscles. MATERIALS AND METHODS: Rats were irradiated with one dose of 10, 15, 20, 25, 30, or 35 Gy and other rats were irradiated with 20 Gy. The thyroarytenoid (TA), posterior cricoarytenoid (PCA), and cricothyroid (CT) muscles were subjected to reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: Two weeks after irradiation with 10, 15, or 20 Gy, all the MyHC type expressions had decreased in a dose-dependent manner in the TA, PCA, and CT muscles, and especially the expression of MyHC IIa decreased much more than the expressions of the other MyHC isoforms in all muscles. In the 20 Gy-irradiated rats, almost all the MyHC isoform expressions declined over 12 weeks in the TA, PCA, and CT muscles, except for the MyHC I expression in the PCA and CT muscle. The MyHC IIa expression was markedly decreased in all the muscles. CONCLUSION: The laryngeal muscles responded differently to radiation, but they showed a time-dependent and long-lasting decrease in the expressions of all the MyHC isoforms in the TA, PCA, and CT muscles. In particular, the expression of the MyHC IIa isoform in all the muscles may be more sensitive to irradiation than the expressions of the other MyHC isoforms.

Introduction to Expanded Endonasal Approach of the Pituitary Fossa: The Role of Rhinologic Surgeon

The expanded endonasal approach (EEA) to the ventral skull base provides endoscopic access from the frontal sinus to the second cervical vertebra. Potential advantages of the EEA include not only improved cosmesis but more importantly, the potential for reduced neurovascular manipulation. EEA is based on the principle of extracapsular dissection with full visualization of important neurovascular structures. There are significant risks of neural and vascular injury associated with EEA, and the reconstruction of dural defects is challenging. Experienced teams including rhinologists and neurosurgeons are needed for successful implementation of EEA. The surgical team must have adequate endoscopic skills to achieve hemostasis and address vascular emergencies. Advantages of having a skilled second surgeon to provide endoscopic visualization include dynamic adjustments of the endoscope to ensure the best view and avoid contact interference of instruments, second surgical opinions in complex anatomical areas, and maintenance of endoscopic views in cases of crisis such as vascular injury. Complications of the EEA such as neurovascular injury, cerebrospinal fluid leaks and infection are the same as those of open approaches. With the advent of the nasoseptal flap, problematic cases involving huge bony defects subsequent to the resection of skull base tumors have been greatly resolved.

Assessment of Anxiety using Beck's Anxiety Inventory in Patients with Vestibular Neuritis / 대한평형의학회지

BACKGROUND AND OBJECTIVES: The intimate relationship of vertigo and anxiety has been previously recognized. Anxiety may have an important influence on recovery of symptoms in vestibular neuritis (VN). The aim of study was to evaluate subjective anxiety of the pre-VN, at the time of onset of VN, and just after vestibular rehabilitation therapy (VRT) using Beck Anxiety Inventory (BAI) questionnaire, respectively. MATERIALS AND METHODS: Twenty-eight patients with VN were asked to complete the BAI and dizziness handicap inventory (DHI). Each of the BAI and DHI was scored. We also evaluated the relationship between the DHI and BAI scores. RESULTS: The VN patients at the time of attack had significantly more anxiety with vertigo and related symptoms (p<0.05). In most patients, anxiety level decreased following VRT. CONCLUSION: These findings indicate that almost every VN patients can recovery from anxiety as vertigo regressed. However, the emotional support as well as physical and/or functional rehabilitation may be required to provide a more rapid and complete return to normal daily lives for these patients.

A Case of Sudden Sensorineural Hearing Loss due to Intralabyrinthine Hemorrhage / 대한이비인후과학회지

Sudden sensorineural hearing loss (SNHL) that is due to intralabyrinthine hemorrhage (ILH) is a rare condition. A 64-year-old female presented with vertigo and a sudden onset of SNHL in the left ear. The audiograms revealed a severe left-sided SNHL. The brain MRI showed a hyperintense signal in the labyrinth on the pre-contrast T1-weighted image. Caloric testing revealed a decreased caloric response of 63% in the left side compared to the right side. The patient was given a course of prednisolone followed by a course of intratympanic dexamethasone injection; this was followed by a course of vestibular rehabilitation therapy. Her hearing substantially recovered from severe to mild SNHL following a combination of oral and intratympanic steroid therapy. We report here on an unusual case of sudden SNHL due to ILH with a review of the related literatures.

Characteristics of Clinically Invasive Aspergillosis in Sphenoid Sinus

BACKGROUND AND OBJECTIVES: Because of the close vicinity of the orbit to the sphenoid sinus, invasive fungal sphenoiditis is a difficult disorder to correctly diagnose and treat. The aims of this study were to examine clinical characteristics of invasive sphenoidal aspergillosis and to discuss diagnostic and therapeutic priorities. MATERIALS AND METHODS: Eleven patients who presented with sphenoidal aspergillosis in our department since 1997 were reviewed retrospectively. These patients were classified into two groups:a clinically invasive group who experienced aggravation even after endoscopic surgery and required further treatments, including antifungal agent, and a non-invasive group who were cured after surgery. The presenting symptoms, age, underlying systemic diseases, CT and MRI findings, treatment modality, and prognosis were reviewed between the clinically-invasive fungal and non invasive groups. RESULT: Only the clinically invasive group presented with visual disturbance. Visual disturbance developed rapidly within several days. Age over 50 years and diabetes may be associated with visual disturbance. Bony erosion and expanding lesions upon CT or MRI were observed more frequently in the clinically invasive group than in the non-invasive group. Enhancement outside the sphenoid sinus was demonstrated only in the clinically invasive group. Endoscopic sinus surgery was performed with additional amphoterichin B and/or mega-dose steroid therapy. Recovery from visual disturbance was poor. Moreover, mega-dose steroid therapy had no effect on symptoms and caused two complications, uncontrolled diabetes and pneumonia. CONCLUSION: Aged diabetic patients, rapidly progressing eye symptoms, bony erosion, and expanding sphenoid lesions upon imaging incur high suspicion of invasiveness in a sphenoid fungus ball. Endoscopic sinus surgery to remove sphenoid fungus balls, as well as systemic antifungal treatment, should be started as early as possible in patients with these clinical features.

Organized Hematoma Presenting with Periorbital Swelling: A Case Report and Review of Literatures

Organized hematoma of the maxillary sinus is a rare clinical disease. We report a case of organized hematoma of the maxillary sinus presenting with acute sinusitis. This is the first article describing such a case. Included is a review of the literatures, highlighting the diagnostic signs of organized hematoma of the maxillary sinus.

Assessment of Subjective Symptoms Using Dizziness Handicap Inventory in Patients with Vestibular Neuritis / 대한평형의학회지

BACKGROUND AND OBJECTIVES Vestibular neuritis (VN) is one of critical life events that can affect physical, emotional, and function aspects of quality of life. Most patients recover well from VN within 6 months following the onset of the disease. However, they can still interfere with their daily lives in some patient with VN. Dizziness Handicap Inventory (DHI) was developed to assess the self-perceived handicapping effects imposed by vestibular system diseases. The aim of study was to evaluate subjective symptoms among the pre-VN, at the time of onset of VN, and post-VN using DHI questionnaire, respectively. MATERIALS AND METHODS Twenty patients with VN were asked to complete the DHI by mailed survey. Each of the DHI was scored. We also evaluated the relationship between the DHI scores and degree of the canal paresis on the caloric test. RESULTS Almost every patients had substantially improved its subjective symptoms in 6 months after VN. There was no correlation between the canal paresis in the lesion ear and DHI scores at the time of VN. CONCLUSION The results of this study suggest that most patients recovery well from VN without any handicap, but the emotional support in combination with physical and/or functional rehabilitation should be required to provide early resumption of normal activity

Shielded Swab: A New Swab Technique Avoiding Contamination in Endoscopically Guided Middle Meatal Culture / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Endoscopically guided middle meatal culture is recommended to determine organ-specific antibiotic therapy in sinusitis. This study was designed to decrease the chance of contamination in endoscopically guided middle meatal swab through a shielded pathway using a sterile straw to bypass the contaminated area in the nose from the vestibule to the middle meatus. SUBJECTS AND METHOD: Seventeen healthy volunteers underwent endoscopically guided middle meatal culture. With or without the sterilization of the nasal vestibule, endoscopically guided middle meatal culture was performed by using a sterile cotton swab (routine swab) and using a sterile cotton swab through a sterile straw (shielded swab). We compared the contamination rates between the routine swab versus shielded swab. RESULTS: With and without the sterilization of the nasal vestibule, the contamination rates of the routine swab was 11.7% and 64.7%, respectively and the contamination rates of the shielded swab was 5.8% in both. CONCLUSION: In endoscopically guided middle meatal culture, the contamination rates was significantly decreased by using the shielded swab without sterilization of the nasal vestibule. This study suggests that the shielded swab is a new and reliable swab method that can be used easily and simply at the office.

A Case Report of Lou Gehrig's Disease Presenting with Rhinolalia Aperta in Its Early Stage / 대한이비인후과학회지

Lou Gehrig's disease, also called amyotrophic lateral sclerosis, is a chronic progressive motor neuron disease of an unknown etiology, characterized by upper and lower motor neuron degeneration with a resultant progressive weakness of bulbar muscles or the extremities. The early symptoms may include twitching, cramping, muscle weakness of distal extremities and slurred nasal speech. Rhinolalia aperta is abnormal speech attributable to inadequate velopharyngeal closure. Hypernasality is thequality of voice in which the emission of air through the nose is excessive due to velopharyngeal insufficiency so that the voice is highpitched and speech intelligibility deteriorates. We experienced a rare case of Lou Gehrig's disease presenting with rhinolia aperta in its early stage. We report the case with a literature review.

Herpes Zoster Oticus Involving Superior And Inferior Vestibular Nerve Without Facial Nerve Palsy

Herpes zoster oticus (HZO) is characterized by auricular vesicles, facial palsy and vestibulocochlear dysfunction. The 8th cranial nerve can be most frequently involved. Rarely, it may be associated with the involvement of 5th, 6th, 9th, 11th or 12th cranial nerve. However, only few cases of HZO involving vestibular nerve without facial nerve palsy have been previously reported. We experienced an unusual case of 38-year-old woman who presented with auricular vesicles, otalgia, and vertigo of whilrling nature but not with facial palsy. Vestibular evoked myogenic potential (VEMP) and caloric tests that were performed to determine which division of vestibular nerve was involved demonstrated that decreased responses in this case. We report a case of HZO involving superior and inferior vestibular nerve without facial palsy that was confirmed by VEMP and caloric tests with a review of literature.

Rat Model of Staphylococcal Enterotoxin B-Induced Rhinosinusitis

OBJECTIVES: It has been proposed that microbial persistence, superantigen (SA) production, and host T-cell response may be involved in the development of chronic rhinosinusitis. According to the SA hypothesis, a single intranasal application of SA such as staphylococcal enterotoxin B (SEB) may induce chronic eosinophilic rhinosinusitis. This study aimed to develop a rat model of rhinosinusitis induced by intranasally applied SEB. METHODS: Forty microliter of SEB (100 microgram/mL) or phosphate buffered saline was applied intranasally through each naris in 4 weekold Sprague-Dawley test rats (N=36) and controls (N=16), respectively. Following sacrifice at 1, 5, 14, and 28 days, the obtained nasal cavity and sinuses were prepared for histologic investigation. The histologic sections were examined in a blind manner for the ratio of the sinus spaces occupied by inflammatory cell clusters and the number of inflammatory cells in the lamina propria. RESULTS: Infiltration of neutrophils in the lamina propria and appearance of neutrophil clusters in the sinus spaces were observed in the SEB-applied rats. The ratio of the sinus spaces occupied by neutrophil clusters and the number of neutrophils infiltrated in the lamina propria increased significantly at day 1 as compared with the control rats. CONCLUSION: Intranasally applied SEB induces acute neutrophilic rhinosinusitis in rats. Eosinophilic inflammation was not demonstrated. The mere presence of SA in the nose does not necessarily induce SA-induced inflammation, as suggested by the SA hypothesis.