Collagenous Fibroma at the Surgical Site after Thyroidectomy for Papillary Thyroid Carcinoma / 대한이비인후과학회지

Collagenous fibroma (CF) is a rare benign tumor that occurs at various anatomical sites including the head and neck. CFs are often omitted from differential diagnosis before surgery. We describe a case of CF in a 54-year-old male who presented with a growing neck mass of 1-year duration at the site of previous right hemithyroidectomy for papillary thyroid carcinoma (PTC). Although radiologic findings demonstrated a benign tumor, surgical excision was carried out per patient’s preference and to rule out recurrent thyroid cancer. The mass was severely adherent to the surrounding muscles, but was resected completely without any injury to the adjacent structures. Histological studies revealed CF. The postoperative course was uneventful without vocal fold paralysis. CFs can be a diagnostic challenge in preoperative evaluation. Conservative excision was sufficient in most cases without recurrence. Clinicians should be aware of CFs in diagnosis, especially in postoperative site.

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

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

A Case of Cranial Fasciitis in Midface / 대한이비인후과학회지

Cranial fasciitis is an uncommon subset of nodular fasciitis composed of spindle cells and myxoid stroma. This is not considered as a true neoplasm, as it occurs mostly in the scalp as a rapidly growing mass accompanied by adjacent bony structure destruction. There are few cases of cranial fasciitis reported in the literature; however, we experienced a case of a 2-year-old girl with swelling of midface. Subtotal resection was performed and the final pathological result confirmed cranial fasciitis. We report this rare case with a review of the literature.

A Case of Aspergillus Clival Abscess Treated by Endoscopic Removal / 대한이비인후과학회지

Aspergillus clival abscess, especially without a sphenoid sinus lesion, is a very rare infection of central nervous system. In this report, we describe the successful treatment of a patient with aspergillus clival abscess. A 63-year-old man was referred to our hospital with the diagnosis of sphenoid mass lesion in magnetic resonance image accompanied by headache and diplopia. The computed tomography scan revealed a clival cystic lesion without connection with the sphenoid sinus. The patient underwent the endoscopic endonasal clival approach and histopathological examination revealed aspergillosis. Postoperatively, the patient was given IV amphotericin-B for 2 weeks and oral voriconazole for 3 months. After surgery, patient's headache and diplopia disappeared. Aspergillus abscess originating from the skull base is rare but has a high mortality rate. Histopathological confirmation via endonasal approach and intensive antifungal therapy should be started for a successful treatment.

Acute Rhinosinusitis in Prominently Pneumatized Sphenoid Sinus Presenting with Unilateral Abducens Nerve Palsy / 대한이비인후과학회지

Acute rhinosinusitis is a rare cause of abducens nerve palsy. Most reported cases with VIth cranial nerve palsy associated sphenoid sinusitis are fungal sphenoid sinusitis, mucocele, or severe bacterial sinusitis. In this report, we present a patient with acute mild sphenoid sinusitis presented as abducens nerve palsy associated with prominent sphenoid pneumatization to the Dorello's canal.

Multifocality and Bilaterality of Papillary Thyroid Microcarcinoma

OBJECTIVES: Papillary thyroid carcinomas frequently occur as two or more separate foci within the thyroid gland (18%-87%). However, those multifocal tumors are easy to be undetected by preoperative radiologic evaluations, which lead to remnant disease after initial surgery. We aimed to study the incidence of multifocal papillary thyroid microcarcinomas (PTMCs), diagnostic accuracy of preoperative radiologic evaluation, predictive factors, and the chance of bilateral tumors. METHODS: Two hundred and seventy-seven patients with PTMC were included in this study. All patients underwent total thyroidectomy as an initial treatment. Medical records, pathologic reports, and radiological reports were reviewed for analysis. RESULTS: Multifocal PTMCs were detected in 100 of 277 patients (36.1%). The mean number of tumors in each patient was 1.6+/-1.1, ranging from 1 to 10. The additional tumor foci were significantly smaller (0.32+/-0.18 cm) than the primary tumors (0.63+/-0.22 cm) (P<0.001). There was no significant relationship between primary tumor size and the presence of contralateral tumors. With more tumors detected in one lobe, there was greater chance of contralateral tumors; 18.8% with single tumor focus, 30.2% with 2 tumor foci, and 46.2% with 3 or more tumor foci in one lobe. Sensitivity of preoperative sonography was 42.7% for multifocal tumors and 49.0% for bilateral tumors. With multivariate analysis, nodular hyperplasia was the only significant factor for multifocal tumors. CONCLUSION: In cases of PTMCs, the incidence of multifocal tumors is high. However, additional tumor foci are too small to be diagnosed preoperatively, especially under the recent guidelines on radiologic screening tests for papillary thyroid carcinoma. Multifocal PTMCs have high risk of bilateral tumors, necessitating more extensive surgery or more thorough follow-up.

Evaluation of Lymph Nodes in Patients with Concurrent Papillary Thyroid Carcinoma and Cervical Tuberculous Lymphadenitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To determine the diagnostic clues to differentiate tuberculous lymph node infection from nodal metastasis in patients with both papillary thyroid carcinoma and cervical tuberculous lymphadenitis. SUBJECTS AND METHOD: We retrospectively reviewed 11 patients suffering concurrently from papillary thyroid carcinomas with cervical tuberculous lymphadenitis. Nine of the 11 patients underwent preoperative neck ultrasonography (US) and seven CT scans. Using the surgical pathology as the reference standards, the results of the preoperative diagnostic tools were re-evaluated according to lymph node level-based analysis. US and CT features were also compared between metastatic nodes and tuberculous lymphadenitis. RESULTS: Preoperative CT could localize the involved lymph node levels and differentiate tuberculous infection from metastasis of thyroid carcinoma in only two of seven patients. The site of the involved lymph nodes, the presence of pulmonary tuberculosis, and the tumor volume of the thyroid carcinoma were the clues to diagnose the lymph node status. However, in five of seven cases, CT could not differentiate tuberculosis from metastasis in the lymph nodes. The morphological characteristics of lymph nodes seen on CT and US did not differ between tuberculous infection and metastasis of papillary thyroid carcinomas. CONCLUSION: Pre-operative CT or US does not provide differential information about lymph node status between tuberculous infection and metastasis in patients with concurrent papillary thyroid carcinomas and cervical tuberculous lymphadenitis. Rather, clinical characteristics such as the site of the involved lymph nodes, the primary tumor burden, and the associated clinical features can help the physician differentiate between them.

Initial Adherence to Autotitrating Positive Airway Pressure Therapy: Influence of Upper Airway Narrowing

OBJECTIVES: There is still debate concerning the reason for the high initial failure rate of positive airway pressure (PAP) treatment. The objective of this study is to investigate the factors of the initial adherence to PAP, with an emphasis on the role of upper airway narrowing. METHODS: The patients were divided into two groups according to the continuation of therapy within the first three months of treatment. The demographic and polysomnographic findings, the minimal nasal cross sectional area (MCA), the degree of palatine tonsilar hypertrophy (PTH) and the modified Mallampati grade of the oropharynx inlet (Orophx) were compared between the study groups. RESULTS: Among 36 patients, 23 continued the auto-adjusting positive airway pressure (APAP) therapy (the adherent group) and 13 discontinued APAP within three months (the non-adherent group). The apnea-hypopnea index (AHI) was significantly higher in the adherent group than in the non-adherent group (P<0.001). The AHI distributions of the two groups are extremely different. Thirteen of the 23 patients in the adherent group had an AHI of more than 60/hr, while none of the patients in the non-adherent group had an AHI of more than 60/hr. In the patients with an AHI from 15 to 60/hr, the MCA at the wide side of the nasal cavity and the sum of the MCAs of both sides were significantly larger in the adherent group than those values in the non-adherent group (P=0.004). The PTH and the Orophx were not significantly different between the two groups. CONCLUSION: AHI is a definite significant factor of adherence to APAP therapy. The dimension of the nasal cavity has an influence on initial APAP adherence in the patients who have a not too high level of AHI.

Surgical Outcomes of Jugular Foramen Tumors; Postoperative Facial Nerve Palsy and Lower Cranial Nerve Palsy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Surgical treatment of jugular foramen tumors can have significant complications such as facial nerve palsy due to complicated regional anatomy. In this study, we investigated the outcomes and complications of surgical approach to the jugular foramen tumors. SUBJECTS AND METHOD: Thirteen patients had operations for their tumors around jugular foramen with a mean follow-up period of 52 months. We reviewed their medical records with emphasis on postoperative facial nerve palsy and other low cranial nerve palsies. RESULTS: There were jugular foramen schwannoma (n=9), glomus jugulare (n=2), meningioma (n=1) and chondrosarcoma (n=1). Gross total removal was achieved in 12 patients. Facial nerves were rerouted at genigulate ganglion (long rerouting) or at the second genu (short rerouting). Mastoidectomies were performed with canal wall-up (CWU) fashion or with canal wall-down (CWD) fashion. The mean size of tumor with long rerouting was significantly larger than that with short rerouting (p=0.037). Facial nerve palsy (FNP) greater than House-Brackmann grade (HB grade) III remained for more than 6 months in a patient. Low cranial nerve palsies were developed in 3 patients. CONCLUSION: Surgical treatment of jugular foramen tumors had a good local control rate with a low rate of complications. Depending on the size and location of tumors, detailed surgical methods can be determined to avoid unnecessary manipulation of facial nerve and loss of hearing.

The Effect of Lower Airway Disease on the Severity of Chronic Rhinosinusitis

BACKGROUND AND OBJECTIVES: The relationship between the upper airway disease and the lower airway disease has been studied for several decades. In this study, we propose to investigate the prevalence of asthma, asymptomatic bronchial hyperresponsiveness (aBHR) and small airway disease among the chronic rhinosinusitis (CRS) patients and to evaluate their influence on the severity of CRS. MATERIAL AND METHODS: For the evaluation of lower airway diseases, sixty-eight adult patients with CRS underwent skin prick tests, pulmonary function tests with or without bronchodilator tests and methacholine bronchial provocation tests. The severity of CRS was determined in accordance to three factors ; subjective symptoms, the degree of nasal polyposis and the extent of disease on the CT scan. RESULTS: Asthma, aBHR and small airway disease were diagnosed among seven (10.3%), five (7.4%) and eleven (16.2%) patients, respectively. The lower airway diseases had no significant influence on the severity of CRS. CONCLUSION: CRS patients may have various lower airway diseases, symptomatic or asymptomatic, which should be considered when managing CRS patients.

Intranasal Helicobacter Pylori Colonization in Chronic Rhinosinusitis Patients / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Helicobacter pylori (HP) has been reported to be detected in lower esophagus, palatine tonsil, and adenoid. The object of this study was to investigate the prevalence of HP in the nasal cavity of chronic rhinosinusitis (CRS) patients and compare the results with those of healthy controls. SUBJECTS AND METHOD: 43 patients aged 18 to 68 years with CRS who underwent endoscopic sinus surgery and 16 healthy controls aged 24 to 72 years without sinus diseases were enrolled in this study. Tissue samples were collected from nasal polyp or the mucosa of sphenoethmoidal recess. HP infection of nasal cavity was investigated using rapid urease (CLO) test and immunohistochemical (IHC) analysis. GER symptoms and esophagogastroscopic findings were gathered by questionnaire or medical records. RESULTS: HP was detected in nasal cavity by CLO test in 17 of 43 patients (40%) with CRS compared with none of 16 healthy controls (0%) (p=0.003), and 19 of 43 patients (44%) by IHC analysis compared with 2 of 16 healthy controls (13%) (p=0.032). Eleven of 43 patients (26%) were positive in both CLO test and IHC analysis but none of controls (0%) was positive in both two tests (p=0.026). Four of 8 patients (50%) who complained GER specific symptoms were HP positive in both two tests (p=0.033). CONCLUSION: HP was detected in nasal cavity and it was more prevalent in patients with CRS than healthy controls without sinus diseases. GER may have a positive correlation with the colonization of HP. However, whether HP is a causative agent for CRS or a result of CRS is not known.

Diagnosis and Treatment of Extracranial Arteriovenous Malformations in the Head and Neck Region / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Arteriovenous malformation is a vascular malformation with fast-flow shunt from the artery to the vein. Extracranial arteriovenous malformation in the head and neck (HNAVM) is so rare that there have been no systematical reports related to it in Korea. Authors aimed to suggest the treatment protocols for HNAVM through retrospective analysis. SUBJECTS AND METHOD: We reviewed retrospectively the medical records of 19 patients with extracranial HNAVM, who had been diagnosed and treated between 1995 and 2001. Mean follow-up duration was 27.3 months. The mean age at detection was 13.2 years old. The cheek was the most frequently suffered site. We used MRI, angiography, and 99mTechnetium (Tc) RBC scintigraphy for the diagnosis and follow-up of HNAVM. For the treatment, ethanol sclerotherapy, excision, and embolization were adopted alone or in variable combination. RESULTS: Angiography was confirmative of the diagnosis and MRI was excellent in evaluating the extent of the disease. Ethanol sclerotherapy was used as the first line of treatment for 11 cases. For others, surgical excision combined with embolization was used as the first line of treatment for 7 patients and the second choice for 6 patients. 99mTc RBC scintigraphy was useful in quantifying the response after treatment. Fifteen out of 19 patients finally achieved 75% or more reduction in their size of lesions. There were 5 permanent complications from the total of 37 procedures. CONCLUSION: For those cases of HNAVM that had the nidus accessible via the percutaneous route, ethanol sclerotherapy worked as the first-line treatment. For other HNAVM cases, surgical excision with embolization might be the best choice of treatment.

Factors Affecting Treatment of Benign Paroxysmal Positional Vertigo

BACKGROUND AND OBJECTIVES: Benign paroxysmal positional vertigo (BPPV) is one of the most common clinical entities encountered in a dizziness clinic. Treatment of this disease, canalith repositioning procedures, have been reported to be successful in 44-90%. Treatment requires only one treatment visit in most patients. However, there are significant numbers of patients who require multiple treatment visits for relief. The goal of this study is to identify variables that may be associated with these difficult to treat cases. METHODS: Retrospective review was performed for the patients diagnosed as BPPV at Samsung medical center. Variables for statistical analysis included age, sex, involved canal, presence of bilateral disease, involvement of unilateral multiple canals, presence of recent head trauma, presence of chronic otitis media, history of middle ear surgery, history of otologic surgery, unilateral vestibular loss, accompanying sudden SNHL, underlying disease such as hypertension or diabetes, change of involved canal during treatment course and number of treatment visits. Statistical analysis using Pearson chi-square test was performed. RESULTS: Three hundred thirty-one patients with BPPV who received treatment were identified from 2001 to 2005. 85.2% required one treatment visit, 12.4% required a second treatment visit, and 98.2% were successfully treated after three treatment visits. Variables such as bilateral disease, anterior canal BPPV, post-traumatic BPPV, duration of symptom before treatment and change of involved canal during treatment were significantly related with number of treatments. CONCLUSION: Patients with anterior semicircular canal BPPV or bilateral BPPV or with recent head trauma or longer duration of symptom are more likely to require multiple visits for canalith repositioning.