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Background and Objectives@#Voice change after thyroidectomy is a common complication that affects a patient’s quality of life. In this study, we aimed to compare voice outcomes between minimally invasive open hemithyroidectomy (MIOT) and conventional hemithyroidectomy.Materials and Method We enrolled 215 patients who underwent hemithyroidectomy performed by an experienced surgeon at our institute between June 2017 and December 2021. All patients underwent voice evaluations, including subjective and objective assessments, preoperatively and 2 weeks and 2 months postoperatively. @*Results@#Sixty-one patients underwent MIOT (M group) and 154 patients underwent conventional hemithyroidectomy (C group). There were 50 female (82.0%) and 11 male (18.0%) in the M group, and 129 female (83.8%) and 25 male (16.2%) in the C group. In both groups, the thyroidectomy-related voice questionnaire score increased at 2 weeks and 2 months postoperatively. However, no statistically significant differences were observed between the two groups. Voice parameters were analyzed according to sex. There were some changes in the parameters in both groups. However, no statistically significant differences were observed between the two groups. @*Conclusion@#Our study showed no differences in the acoustic results between MIOT and conventional hemithyroidectomy.
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Purpose@#We report the clinical features, diagnoses, and treatments of patients with neuro-ophthalmological diseases presenting to a tertiary referral center emergency room (ER) of South Korea. @*Methods@#We retrospectively analyzed the medical records of 205 patients who visited the ER of the Asan Medical Center and then were referred to our neuro-ophthalmology department from May 2020 to April 2022. The initial diagnoses of ophthalmology residents were compared to the final diagnoses of neuro-ophthalmologists. We describe the symptoms, diagnoses, and treatments. @*Results@#The median time from the onset of symptoms to the ER visit was 3 days; diplopia (49.1%) and vision loss/a visual field defect (38.9%) were the chief complaints. The most common causes of diplopia were isolated cranial nerve 4 (37.5%), 6 (22.9%), and 3 palsy (18.4%) and supranuclear palsy (9.2%). In patients with vision loss/visual field defect, the most common causes were optic (20.5%), ischemic (17.1%), and compressive (8.0%) optic neuropathies. For 121 cases (59.0%), multidisciplinary consultations with the departments of neurology, neurosurgery, and internal medicine were scheduled. After initial management in the ER, 38 diagnoses (18.5%) changed after evaluation by neuro-ophthalmologists. @*Conclusions@#Over half of all neuro-ophthalmology patients presenting to an ER required comprehensive interdisciplinary evaluation and over a third required inpatient treatment.
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Objectives@#. This study aimed to assess predictors of the response to varying durations of proton pump inhibitor (PPI) use and lifestyle modification treatment for laryngopharyngeal reflux disease (LPRD). @*Methods@#. Between October 2014 and June 2016, a prospective, multicenter, open-label, single-cohort, intention-to-treat, observational study was conducted at eight referral hospitals across the Republic of Korea to examine predictors of early and late response to treatment in adult patients (age ≥19 years) with LPRD. Participants underwent standard treatment (PPI [Esomezol] and lifestyle modification) for 3 months. Response to treatment was defined as greater than 50% improvement in reflux symptom index score. The primary outcome was potential predictors of treatment response at 1 and 3 months. The secondary outcome was potential predictors distinguishing early from late responders. @*Results@#. In total, 394 patients were enrolled. Improved sleep habits was a positive predictor (odds ratio [OR], 1.785; 95% confidence interval [CI], 1.06–3.007; P=0.029), while initial alcohol consumption (OR, 0.587; 95% CI, 0.355–0.969; P=0.037) and past medication history (OR, 0.438; 95% CI, 0.215–0.891; P=0.005) were negative predictors of response after 1 month of treatment. High pre-reflux finding score was a positive predictor (OR, 1.187; 95% CI, 1.049– 1.344; P=0.007), while male sex (OR, 0.516; 95% CI, 0.269–0.987; P=0.046), higher depression score (OR, 0.867; 95% CI, 0.784–0.958; P=0.005), and past thyroid hormone medication history (OR, 0.161; 95% CI, 0.033–0.788; P=0.024) were negative predictors of response after 3 months of treatment. Past medication history (OR, 0.438; 95% CI, 0.215–0.891; P=0.023) was the only negative predictor for early responders compared to late responders. @*Conclusion@#. Adult patients with LPRD and a history of prior medication use may require longer treatment durations to achieve a therapeutic response. Future research should explore the incorporation of diverse treatment approaches to improve treatment outcomes for patients exhibiting negative prognostic indicators.
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Background and Objectives@#Parotid cancer is a rare malignancy tumor, constituting about 3% of head and neck cancers. Treatment of parotid carcinoma is challenging because of its rarity and unpredictable clinical course. Therefore, it is important to evaluate risk factors associated with prognosis and to predict adverse outcomes. In this article, we aimed to analyze risk factors associated with recurrence free survival in our 10-year single center retrospective study.Subjects and Method Retrospective medical chart review was performed for patients with parotid gland cancer who underwent parotidectomy with or without adjuvant treatment in our institute 2011 to 2020. Patient demographics, histopathologic results, operative method, treatment outcome were assessed. @*Results@#A total of 8 patients (15%) experienced recurrence. Old age and low body mass index was associated with recurrence. Univariate analysis also revealed that high clinical stage, tumor involvement in deep lobe and facial nerve, postoperative radiotherapy or concurrent chemo radiotherapy, positive resection margin, and high histologic grade were statistically significant with recurrence. Multivariate analysis concluded that facial nerve involvement with tumor was associated with higher incidence of recurrence. Deep lobe and facial nerve involvement, postoperative radiotherapy or concurrent chemo radiotherapy, positive resection margin, clinical stage, and histologic grade were statistically significant factors associated with recurrence free survival. @*Conclusion@#Our 10-year single institute study will be helpful for predicting adverse outcomes in parotid cancer patients.
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Background@#To report the clinical manifestations of non-arteritic anterior ischemic optic neuropathy (NAION) cases after coronavirus disease 2019 (COVID-19) vaccination in Korea. @*Methods@#This multicenter retrospective study included patients diagnosed with NAION within 42 days of COVID-19 vaccination. We collected data on vaccinations, demographic features, presence of vascular risk factors, ocular findings, and visual outcomes of patients with NAION. @*Results@#The study included 16 eyes of 14 patients (6 men, 8 women) with a mean age of 63.5 ± 9.1 (range, 43–77) years. The most common underlying disease was hypertension, accounting for 28.6% of patients with NAION. Seven patients (50.0%) had no vascular risk factors for NAION. The mean time from vaccination to onset was 13.8 ± 14.2 (range, 1–41) days. All 16 eyes had disc swelling at initial presentation, and 3 of them (18.8%) had peripapillary intraretinal and/or subretinal fluid with severe disc swelling. Peripapillary hemorrhage was found in 50% of the patients, and one (6.3%) patient had peripapillary cotton-wool spots. In eight fellow eyes for which we were able to review the fundus photographs, the horizontal cup/ disc ratio was less than 0.25 in four eyes (50.0%). The mean visual acuity was logMAR 0.6 ± 0.7 at the initial presentation and logMAR 0.7 ± 0.8 at the final visit. @*Conclusion@#Only 64% of patients with NAION after COVID-19 vaccination have known vascular and ocular risk factors relevant to ischemic optic neuropathy. This suggests that COVID-19 vaccination may increase the risk of NAION. However, overall clinical features and visual outcomes of the NAION patients after COVID-19 vaccination were similar to those of typical NAION.
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Parathyroid carcinoma (PC) in cases of secondary or tertiary hyperparathyroidism is relatively uncommon, and only a few case reports have described this entity. Although some papers have reported patients with one or two parathyroid malignancies, multiple PC–especially three or more–have been even more rarely reported. Herein, we report a case of secondary hyperparathyroidism due to multiple PCs in a chronic hemodialysis patient. A 54-year-old man with end-stage kidney disease was referred for hyperparathyroidism. He had been diagnosed with chronic kidney disease in 2001 and had begun hemodialysis in 2009. In laboratory tests, intact parathyroid hormone (iPTH) was markedly elevated to 1,144.1 pg/mL (normal range: 15.0–68.3 pg/mL) and serum calcium was mildly elevated to 10.56 mg/dL (normal range: 8.5–10.3 mg/dL). Ultrasonography showed hypoechoic nodules in the posterior part of both thyroid glands. All three nodules showed increased uptake on a 99mTc sestamibi scan. The patient underwent total parathyroidectomy with autotransplantation to the right forearm. Histopathology findings showed three PCs with capsular invasion and one parathyroid hyperplasia. In the immediate postoperative period, the iPTH level dropped from 1,446.8 to 82.4 pg/dL and, after 1 month, to 4.0 pg/dL. This patient needed oral calcium carbonate and active vitamin D to maintain appropriate serum calcium levels. Although multiple PCs are rare, they can cause secondary hyperparathyroidism. Therefore, clinicians should suspect multiple PCs when patients’ serum iPTH levels are exceptionally high. Additionally, since PCs could occur in multiple glands, autotransplantation of the parathyroid gland after parathyroidectomy should be done carefully.
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Background and Objectives@#Papillary thyroid carcinoma (PTC) with lateral neck lymph node metastasis is known as a major risk factor for tumor recurrence after surgical treatment. The aim of this study is to identify risk factors for loco-regional recurrence in patients with PTC with lateral neck lymph node metastasis, which has a high risk of recurrence.Subjects and Method This study involved 319 patients who underwent total thyroidectomy, central lymph node (LN) and lateral LN dissection due to PTC. The patients’ demographics and pathological factors, including lymph node metastasis were retrospectively reviewed. Univariate, multivariate and C-index with variable selection analyses were performed to identify factors associated with recurrence-free survival (RFS). @*Results@#A mean follow-up of 101 months, 35 (10.9%) patients had a loco-regional recurrence. In multivariate analysis according to loco-regional recurrence, patients with a primary tumor of more than 4 cm, multifocality, vascular invasion, and bilateral lateral cervical metastasis were associated with worse RFS. In the variable selection analysis, lateral lymph node metastasis ratio was also statistically significant. @*Conclusion@#PTC with lateral neck lymph node metastasis included tumors larger than 4 cm. Multifocality, vascular invasion, high lateral lymph node metastasis ratio and bilateral neck lymph node metastasis are predictive factors of loco-regional recurrence, and these risk factors should be carefully followed-up after surgery.
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Background and Objectives@#Globus pharyngeus is one of the most common symptoms of patients visiting otorhinolaryngology out-patient clinic, and usually long-lasting, difficult to treat, and frequently recurrent. Mucomyst®, N-acetyl cysteine is an inhalation agent mainly used for mucolysis and reducing inflammation in airway via antioxidative effect. The purpose of this study was to evaluate the efficacy of inhaled Mucomyst® treatment in patients with globus pharyngeus refractory to proton pump inhibitor (PPI).Materials and Method We prospectively evaluated the efficacy of Mucomyst® in relieving symptoms of globus pharyngeus refractory to PPI in nine medical centers. Three hundred and three patients enrolled and finally 229 patients finished the inhaled Mucomyst® therapy for 8 weeks. We analyzed the change of Reflux Symptom Index (RSI), Reflux Finding Score (RFS), Visual Analogue Scale (VAS) for globus, and Globus Pharyngeus Symptom Scale (GPS) after use of Mucomyst® for 4 and 8 weeks. @*Results@#The GPS, RSI, RFS, and VAS score significantly decreased serially in patients who finished 8 week-inhalation treatment. The GPS improvement gap was significantly correlated with initial GPS (p<0.001) in multiple regression analysis. @*Conclusion@#Inhaled Mucomyst® therapy was effective for the reduction of both subjective and objective findings in refractory globus patients. This study might suggest new treatment option for patients with globus. However, further thorough studies would be needed to assess the real effect of inhaled Mucomyst® treatment as a standard treatment for globus.
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Intraoperative neuromonitorng (IONM) has gained wide acceptance as a useful adjunct in identifying and preserving of recurrent laryngeal nerve (RLN) during thyroid surgery. The electromyographic endotracheal tube (EMG-ETT) method is the most widely used and well-validated method for thyroid IONM; however, malpositioning of the tube is a critical shortcoming of the EMG-ETT method. This is the main reason for the low positive predictive value of IONM in thyroid surgery. Needle and skin electrodes can obtain EMG signal regardless of patient position and are easy to apply during surgery and is economical compared to EMG-ETT method. New IONM system using needle or skin electrodes would be an alternative method which can overcome shortcomings of EMG-ETT.
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Completion thyroidectomy is defined as surgical removal of the remnant thyroid tissue after resection of the thyroid gland. The frequency of completion thyroidectomy varies among researchers, but is estimated to be about 5-45%. Completion thyroidectomy may cause complications due to the presence of inflammation, adhesions, swelling, and scars at the surgical site due to the initial surgery. There is still controversy over the indications and timing of completion thyroidectomy. In this review, we would like to summarize the changes in indications for completion thyroidectomy and review the literature on its necessity.
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Branchial cleft cysts are the most common lateral neck mass, and usually have well-delineated cystic structures under ultrasonography. Ultrasonography and fine needle aspiration cytology is very helpful during preoperative diagnosis. However, these cysts may occur in unusual locations and have a sonographic morphology similar to malignant thyroid neoplasm. A 61-year-old woman presented with thyroid nodules, and ultrasonography revealed a 0.8-cm, hypoechoic, solid nodule with microcalcifications in the right lobe of thyroid in the lower portion.Postoperative histopathological examination revealed the 0.8-cm hypoechoic nodule to be a branchial cleft cyst. In addition, concurrent medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) were found. Herein, we present a rare case of branchial cleft cyst mimicking malignant thyroid neoplasm concurrent with medullary and PTC.
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Background and Objectives@#During speech, the vocal folds oscillate at frequencies ranging from 100–200 Hz with amplitudes of a few millimeters. Mechanical stimulation is an essential factor which affects metabolism of human vocal folds. The effect of mechanical vibration on the cellular response in the human vocal fold fibroblasts cells (hVFFs) was evaluated.Materials and Method We created a culture systemic device capable of generating vibratory stimulations at human phonation frequencies. To establish optimal cell culture condition, cellular proliferation and viability assay was examined. Quantitative real time polymerase chain reaction was used to assess extracellular matrix (ECM) related and growth factors expression on response to changes in vibratory frequency and amplitude. Western blot was used to investigate ECM and inflammation-related transcription factor activation and its related cellular signaling transduction pathway. @*Results@#The cell viability was stable with vibratory stimulation within 24 h. A statistically significant increase of ECM genes (collagen type I alpha 1 and collagen type I alpha 2) and growth factor [transforming growth factor β1 (TGF-β1) and fibroblast growth factor 1 (FGF-1)] observe under the experimental conditions. Vibratory stimulation induced transcriptional activation of NF-κB by phosphorylation of p65 subunit through cellular Mitogen-activated protein kinases activation by extracellular signal regulated kinase and p38 mitogen-activated protein kinases (MAPKs) phosphorylation on hVFFs. @*Conclusion@#This study confirmed enhancing synthesis of collagen, TGF-β1 and FGF was testified by vibratory stimulation on hVFFs. This mechanism is thought to be due to the activation of NF-κB and MAPKs. Taken together, these results demonstrate that vibratory bioreactor may be a suitable alternative to hVFFs for studying vocal folds cellular response to vibratory vocalization.
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Branchial cleft cysts are the most common lateral neck mass, and usually have well-delineated cystic structures under ultrasonography. Ultrasonography and fine needle aspiration cytology is very helpful during preoperative diagnosis. However, these cysts may occur in unusual locations and have a sonographic morphology similar to malignant thyroid neoplasm. A 61-year-old woman presented with thyroid nodules, and ultrasonography revealed a 0.8-cm, hypoechoic, solid nodule with microcalcifications in the right lobe of thyroid in the lower portion.Postoperative histopathological examination revealed the 0.8-cm hypoechoic nodule to be a branchial cleft cyst. In addition, concurrent medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) were found. Herein, we present a rare case of branchial cleft cyst mimicking malignant thyroid neoplasm concurrent with medullary and PTC.
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Objectives@#. Facial nerve monitoring (FNM) can be used to identify the facial nerve, to obtain information regarding its course, and to evaluate its status during parotidectomy. However, there has been disagreement regarding the efficacy of FNM in reducing the incidence of facial nerve palsy during parotid surgery. Therefore, instead of using electromyography (EMG) to identify the location and state of the facial nerve, we applied an intraoperative neuromonitoring (IONM) system using a surface pressure sensor to detect facial muscle twitching. The objective of this study was to investigate the feasibility of using the IONM system with a surface pressure sensor to detect facial muscle twitching during parotidectomy. @*Methods@#. We evaluated the stimulus thresholds for the detection of muscle twitching in the orbicularis oris and orbicularis oculi, as well as the amplitude and latency of EMG and the surface pressure sensor in 13 facial nerves of seven rabbits, using the same stimulus intensity. @*Results@#. The surface pressure sensor detected muscle twitching in the orbicularis oris and orbicularis oculi in response to a stimulation of 0.1 mA in all 13 facial nerves. The stimulus threshold did not differ between the surface pressure sensor and EMG. @*Conclusion@#. The application of IONM using a surface pressure sensor during parotidectomy is noninvasive, reliable, and feasible. Therefore, the IONM system with a surface pressure sensor to measure facial muscle twitching may be an alternative to EMG for verifying the status of the facial nerve.
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Background and Objectives@#During speech, the vocal folds oscillate at frequencies ranging from 100–200 Hz with amplitudes of a few millimeters. Mechanical stimulation is an essential factor which affects metabolism of human vocal folds. The effect of mechanical vibration on the cellular response in the human vocal fold fibroblasts cells (hVFFs) was evaluated.Materials and Method We created a culture systemic device capable of generating vibratory stimulations at human phonation frequencies. To establish optimal cell culture condition, cellular proliferation and viability assay was examined. Quantitative real time polymerase chain reaction was used to assess extracellular matrix (ECM) related and growth factors expression on response to changes in vibratory frequency and amplitude. Western blot was used to investigate ECM and inflammation-related transcription factor activation and its related cellular signaling transduction pathway. @*Results@#The cell viability was stable with vibratory stimulation within 24 h. A statistically significant increase of ECM genes (collagen type I alpha 1 and collagen type I alpha 2) and growth factor [transforming growth factor β1 (TGF-β1) and fibroblast growth factor 1 (FGF-1)] observe under the experimental conditions. Vibratory stimulation induced transcriptional activation of NF-κB by phosphorylation of p65 subunit through cellular Mitogen-activated protein kinases activation by extracellular signal regulated kinase and p38 mitogen-activated protein kinases (MAPKs) phosphorylation on hVFFs. @*Conclusion@#This study confirmed enhancing synthesis of collagen, TGF-β1 and FGF was testified by vibratory stimulation on hVFFs. This mechanism is thought to be due to the activation of NF-κB and MAPKs. Taken together, these results demonstrate that vibratory bioreactor may be a suitable alternative to hVFFs for studying vocal folds cellular response to vibratory vocalization.
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Visual identification of recurrent laryngeal nerve (RLN) is considered as a gold standard of RLN preservation during thyroid surgery. Intraoperative neuromonitoring (IONM) is classified into the intermittent type and continuous type and helps surgeons identify the functional integrity of RLN and predict the postoperative vocal cord function. RLN injury during thyroid surgery is associated with tumor factors and surgeon factors. Tumor factors mean such as direct tumor invasion, adhesion of RLN to the tumor, and compression by a large thyroid tumor. Surgeon factors include nerve transection, stretching, thermal injury, and ligation injury. A recent meta-analysis reported that the IONM could reduce the RLN injury. Considering various nerve injury mechanism, we suggest that using both I-ONM and C-IONM together is more effective method in preventing nerve damage than using I-IONM alone.
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Background and Objectives@#Presbyphonia is characterized by hoarse, breathy, weak vocal intensity. Extracellular matrix (ECM) in lamina propria (LP) of the vocal folds play an important role in voice production, and change of ECM according to the aging leads to the presbyphonia. The aim of this study was to investigate the histologic analysis of aging vocal fold of rat.Materials and Method Six and twenty two months old Sprague-Dawley rats (n=8, each group) were used and classified into young (six months old rats) and old (twenty two months old rats) group. Histologic analysis and immunohistochemical staining for ECM of LP were performed. @*Results@#Overall cellular density was significantly decreased in old rat group. Elastin fibers of LP were significantly decreased in old rat group. Type I collagen was significantly increased in old rat group. Type III collagen did not show significant difference. Hyaluronic acids did not show significant difference in Alcian blue staining and immunohistochemical staining. @*Conclusion@#Decreased general cellular density and elastin fiber and increased type I collagen were observed in the LP of vocal folds of aging rats. These ECM changes might to contribute the aging voice.
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Background and Objectives@#The purpose of this study was to investigate the effect of unvoiced segments on the cepstral analysis in patients with vocal cord paralysis (VCP).Subjects and Method A total 302 subjects (173 subjects with VCP and 129 normal voice subjects) participated in this study. The sustained vowel /a/ 2 seconds and one sentence of ‘Sanchaek’ were edited, and analyzed by Praat script. The cepstral analyses were performed using sustained vowel (SV), continuous speech (CS), and extracted continuous speech (EXT) samples. The auditory-perceptual (AP) rating was also completed by three raters. @*Results@#First, there were significant differences in all variables except low-to high spectral ratio(L/H ratio)_EXT between two groups. Second, cepstral peak prominence (CPP), smoothed cepstral peak prominence (CPPS), and L/H ratio showed significant differences in SV, CS, and EXT samples. Third, cepstral measurements were highly correlated with the AP ratings. Finally, the level of discrimination of dysphonia estimated from CPP and CPPS gotten from SV and CS values was more than area under the curve (AUC) of 0.941. AUC of 0.880 or more was also found in EXT. @*Conclusion@#In this study, we confirmed that both CS and EXT are highly predictive of pathologic speeches. Further study will also need to be validated for a more diverse group of voice disorders.
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Objectives@#. The loss of signal during intraoperative neuromonitoring (IONM) using electromyography (EMG) in thyroidectomy is one of the biggest problems. We have developed a novel IONM system with an endotracheal tube (ETT) with an attached pressure sensor instead of EMG to detect laryngeal twitching. The aim of the present study was to investigate the feasibility and reliability of this novel IONM system using an ETT with pressure sensor during thyroidectomy in a porcine model. @*Methods@#. We developed an ETT-attached pressure sensor that uses the piezoelectric effect to measure laryngeal muscle twitching. Stimulus thresholds, amplitude, and latency of laryngeal twitching evaluated using the pressure sensor were compared to those measured using transcartilage needle EMG. The measured amplitude changes by EMG and the pressure sensor during recurrent laryngeal nerve (RLN) traction injury were compared. @*Results@#. No significant differences in stimulus threshold intensity between EMG and the pressure sensor were observed. The EMG amplitude detected at 0.3 mA, increased with increasing stimulus intensity. When the stimulus was more than 1.0 mA, the amplitude showed a plateau. In a RLN traction injury experiment, the EMG amplitude did not recover even 20 minutes after stopping RLN traction. However, the pressure sensor showed a mostly recovery. @*Conclusion@#. The change in amplitude due to stimulation of the pressure sensor showed a pattern similar to EMG. Pressure sensors can be feasibly and reliably used for RLN traction injury prediction, RLN identification, and preservation through the detection of laryngeal muscle twitching. Our novel IONM system that uses an ETT with an attached pressure sensor to measure the change of surface pressure can be an alternative to EMG in the future.
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Papillary thyroid cancer (PTC) has a good prognosis, but the frequency of regional lymph node metastasis is reported to be up to 90%. In most patients with PTC, nodal metastasis occurs in a stepwise fashion, with metastasis beginning in the central cervical compartment, continuing to the ipsilateral cervical compartment. There are many controversies about the necessity of prophylactic central neck dissection (CND) and extent of therapeutic CND for lymph node metastasis. Ipsilateral CND with intraoperative frozen biopsy in PTC is a very sensitive and useful tool for the evaluation of nodal status in the central compartment. The right upper para-esophageal lymph nodes should be removed during dissection in patients with right paratracheal lymph node metastasis. Prophylactic lateral neck dissection (LND) is not recommended, and optimal extent of therapeutic LND is still controversial. Further studies on factors and clinical implications related to suprasternal lymph node metastasis are needed.