A Nasal Myoepithelioma Removed through Preoperative Embolization and Endoscopic Surgery: A Case Report and Literature Review / 대한이비인후과학회지

Myoepithelioma is a rare benign tumor, most frequently located in the salivary gland. However, involvement of an extra-salivary gland is even rarer and very few cases involving the nasal cavity have been reported in the literature. A 51-year-old female patient presented with a complaint of progressive nasal obstruction and occurrence of recurrent epistaxis in the left nasal cavity over several months. A hemorrhagic and erythematous mass occupying the left nasal cavity was observed on physical examination using a nasal endoscope. A preoperative angiogram confirmed that he tumor was receiving blood supply from the sphenopalatine artery. We performed embolization to prevent hemorrhage during surgery; one day later, the lesion was successfully removed through endoscopic excision. Histopathological examination revealed that the tumor contained myoepithelial cells and myxoid stroma. Immunohistochemical studies showed that the tumor was positive for cytokeratin marker and S-100 protein, confirming the diagnosis of myoepithelioma. The patient recovered without any nasal symptoms or postoperative deficits.

Comparison of Three Chromogenic Media for Recovery of Vancomycin-Resistant Enterococci from Rectal Swab Samples / 대한임상미생물학회지

BACKGROUND: Three chromogenic media using direct inoculation were compared with enriched enterococcosel broth for vancomycin-resistant Enterococcus faecium and/or Enterococcus faecalis (VRE) surveillance. METHODS: A total of 174 rectal swabs were included for VRE surveillance. The specimens were transferred in enterococcosel broth (EB). An aliquot of the broth was inoculated onto Brilliance VRE, chromID VRE, and VRESelect media and incubated for up to 48 h. We examined each media and EB after 24 h and 48 h of incubation. When appropriately colored colonies were observed, identification was confirmed using the VITEK-2 system and/or VITEK MS. Vancomycin susceptibility was confirmed by disk diffusion test. The presence of resistance genes was confirmed using Anyplex VanR Real-time Detection (Seegene, Korea). RESULTS: Of the 174 rectal swab specimens, 73 VRE were isolated. For enterococcosel broth, Brilliance VRE, chromID VRE, and VRESelect, the sensitivity at 24 h was 79.2%, 83.3%, 79.2%, and 79.2%, respectively. The sensitivity at 48 h was 91.7%, 93.1%, 91.4%, and 90.3%, respectively. The specificity at 24 h was 85.3%, 97.1%, 98.0%, and 98.0%, while that at 48 h was 79.4%, 85.3%, 95.2%, and 95.1%, respectively. The specificity of chromogenic media at 24 h and 48 h was significantly higher than that of EB. Furthermore, the specificity at 48 h was significantly higher for chromID VRE and VRESelect than Brilliance VRE, although color distinction was easier with VRESelect. CONCLUSION: Based on our results, use of chromID VRE or VRESelect is more reliable and convenient for screening of VRE. In addition, five vanA-positive Enterococcus gallinarum, Enterococcus avium and Enterococcus durans were isolated, and two of them (one E. avium and one E. durans) were detected only on VRESelect.

A Case of Pseudo-Vestibular Neuritis with Contralesional Canal Paresis due to Spontaneous Bilateral Vertebral Artery Dissection / 대한이비인후과학회지

Pseudo-vestibular neuritis is a central pathology of acute vestibular syndrome, characterized by unidirectional nystagmus mimicking acute peripheral vestibulophaty. We report a 39-year-old female patient who developed cerebellar infarction with isolated vertigo, spontaneous nystagmus, a positive head thrust test, and unilateral canal paresis in the contralesional side. The patient had no vascular risk factors. A diffusion-weighted image of the brain showed infarction of medial branch of posterior inferior and superior cerebellar artery on the left side. A magnetic resonance angiography of neck disclosed a wide range of diffused severe stenosis and narrowing of right and left vertebral arteries, respectively. This case suggests the possibility of vestibular ischemia masking the central pathology in isolated vertigo.

Benign Paroxysmal Positional Vertigo with Simultaneous Involvement of Multiple Semicircular Canals

BACKGROUND AND OBJECTIVES: Benign paroxysmal positional vertigo (BPPV) generally involves a single semicircular canal (single canal BPPV) but it has been reported that more than one semicircular canal on either the same or the opposite side can be involved in 6.8-20% of the cases (multiple canal BPPV). In this study, the clinical characteristics of multiple canal BPPV were analyzed and compared to those of single canal BPPV. MATERIALS AND METHODS: Retrospective analysis was performed on 1054 consecutive patients diagnosed with BPPV. Multiple canal BPPV was diagnosed when the combination of typical nystagmus was provoked by the Dix-Hallpike and supine head roll tests. Canalith repositioning maneuver was performed sequentially starting with the semicircular canal causing more severe nystagmus or symptoms. Clinical characteristics and the treatment course were statistically compared between single canal BPPV and multiple canal BPPV. RESULTS: Among the 1054 patients, single canal BPPV was diagnosed in 1005 patients (95.4%) while multiple canal BPPV was diagnosed in 49 patients (4.6%). BPPV involving semicircular canals on the same side was more common (79.6%) than BPPV with bilateral involvement. The most common combination of the involved canals was ipsilateral posterior and horizontal semicircular canals (63.3%). Multiple canal BPPV was significantly more associated with underlying otologic diseases, especially labyrinthitis. Multiple canal BPPV required more treatment sessions and longer duration of treatment to achieve resolution of nystagmus and symptoms. CONCLUSIONS: As all cases of multiple canal BPPV were treated successfully although a longer duration of treatment and more treatment sessions were required compared to single canal BPPV, the results of our study could aid in making an accurate diagnosis and providing appropriate treatment of multiple canal BPPV.

A Case of Labyrinthine Fistula by Cholesteatoma Mimicking Lateral Canal Benign Paroxysmal Positional Vertigo

Acute peripheral vestibulopathy, of which the chief complaint is positional vertigo, comprises benign paroxysmal positional vertigo (BPPV), labyrinthitis, labyrinthine fistula, and cerebellopontine angle tumors. Since the typical presentation of labyrinthine fistulas may be sensorineural hearing loss, positional vertigo, or disequilibrium, it is often difficult to distinguish from BPPV or Meniere's disease. Herein we report a 61-year-old female patient with typical symptoms and signs attributable to geotropic type variant of the lateral semicircular canal BPPV on the left side, who eventually was confirmed as having a labyrinthine fistula from chronic otitis media with cholesteatoma on the left side. This is another case where, even in the presence of isolated vertigo showing typical findings of acute peripheral vestibulopathy, other otologic symptoms and signs must not be overlooked.

Risk Factors for Treatment Failure in Benign Paroxysmal Positional Vertigo / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Particular repositioning maneuver (PRM) have been recommended as a treatment of benign paroxysmal positional vertigo (BPPV). Some patients require multiple treatments for remission, although most of the patients are treated at the first trial of single maneuver. The purpose of this study was to evaluate risk factors for the treatment failure in patients with posterior canal BPPV (p-BPPV) and horizontal canal BPPV (h-BPPV). SUBJECTS AND METHOD: Retrospective review was performed for the 287 patients diagnosed as BPPV visiting the dizziness clinic between February 2011 and August 2012. The diagnostic criteria for BPPV were met by following the guidelines provided by the American Academy of Otolaryngology-Head and Neck Surgery. Patients were classified into two groups: Group 1 (treatment success) that requires only 1 PRM and Group 2 (treatment failure) that requires more than 2 PRMs. We analyzed the relationship between treatment failure and the clinical characteristics, and studied the etiology of BPPV. RESULTS: The study included 183 patients with p-BPPV, 54 patients with h-BPPV (geotropic type), and 50 patients with h-BPPV (apogeotropic type). The type of BPPV and average numbers of PRM required for remission were significantly related with treatment failure by statistical analysis (p<0.05, respectively). Statistically significant correlation was demonstrated between the history of ipsilateral inner ear viral infection (acute vestibular neuritis, sudden sensorineural hearing loss) and treatment failure (p<0.05). CONCLUSION: Multiple PRMs may be required in patients with h-BPPV (apogeotropic type) or with secondary BPPV caused by ipsilateral inner ear viral disease. Clinically, this information may be used to provide helpful information for clinicians performing PRM to treat BPPV.

Solitary Metastasis of Bronchogenic Adenocarcinoma to the Internal Auditory Canal: A Case Report

We report a patient with an isolated metastasis to the internal auditory canal (IAC) of bronchogenic adenocarcinoma. A 58-yr-old man who had received 6-cycle of chemotherapy under diagnosis of non-small cell lung carcinoma (T4N2M0) two years ago was referred to our department with vertigo, right-sided facial paralysis and right-sided hearing loss. A provisional diagnosis of vestibular schwannoma or meningioma involving right IAC was made from magnetic resonance imaging. The patient underwent a translabyrinthine removal of the tumor. Histopathological study of the resected lesion showed a poorly differentiated adenocarcinoma compatible with bronchogenic origin. The patient died 9 months after surgery from extensive brain metastasis despite postoperative radiation therapy. In patients with a previous history of treatment of malignancy elsewhere in the body, the possibility of IAC metastasis must be considered when an IAC lesion is detected.

Videofluoroscopic Evaluation of Swallowing in Patients with Amyotrophic Lateral Sclerosis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Dysphagia in patient with amyotrophic lateral sclerosis (ALS) is a critical symptom for prognosis. Proper evaluation and follow-up of their dysphagia is also important in management. Videofluoroscope is the gold standard method for evaluation of swallowing in ALS patients. The object of this study is to evaluate their dysphagia using videofluoroscope, on the basis of which we can plan the optimal rehabilitation method. SUBJECTS AND METHOD: The clinical records and videofluoroscopes of 7 ALS patients were reviewed. All patients were classified according to Hillel's ALS swallowing score. We analysed their videofluoroscopes and implied proper treatment strategies on the basis of those findings. RESULTS: All patients had dysfunction of tongue. In the early stage, dysphagia was solely attributable to oral phase dysfunction. In the advanced stage, pharyngeal phase was also affected. In some patients, cricopharyngeal dysphagia and aspiration were observed. After various form of treatment such as tongue exercise, position change, swallowing maneuver, tube feeding, and botulinum toxin injection to cricopharyngeal muscle, we could observe improvement in swallowing function. CONCLUSION: Videofluoroscope is a good method for evaluating patients with ALS. By applying tailored treatment strategies on the basis of videofluoroscopic finding, we can properly manage patients with ALS and eventually improve their quality of life.

A Case of Postobstructive Pulmonary Edema Following Tracheotomy / 대한이비인후과학회지

Postobstructive pulmonary edema is a recognized complication of acute airway obstruction, especially after endotracheal extubation. It usually follows relief of the obstruction and is likely to be of non- cardiogenic origin. The mechanism by which an upper airway obstruction results in pulmonary edema is likely by the combination of the increased reduction of intrapulmonary pressure, increased capillary permeability and hypoxia. The application of moderate continuous positive airway pressure in conjunction with the administration of diuretics usually clears pulmonary edema in these clinical settings within 24 hours. We encountered a rare case of a 47-years-old female with a postobstructive pulmonary edema that occurred in a patient after relief of upper airway obstruction following intubation of the trachea

Clinical Analysis of Hearing Loss after Mild Head Trauma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: We evaluated the clinical characteristics of hearing impairment in patients who suffered a blunt head trauma without any organic problems, including temporal bone fracture or intracranial hemorrhage. SUBJECTS AND METHOD: This retrospective study examined 42 patients presenting with hearing impairment after blunt head trauma within five recent years. This study included only patients without temporal bone fracture or intracranial hemorrhage. RESULTS: Most patients (90.5%) complained of associated auditory symptoms including tinnitus, dizziness, earfullness and otalgia as well as headache. In 38 patients (90.5%), the symptom was developed on the injured day. Fifteen ears of 13 patients showed sensorineural hearing loss, 2 ears of 2 patients conductive hearing loss, and 10 ears of 8 patients mixed hearing loss. Twenty-four ears of 22 patients showed sensorineural hearing loss only above 4 kHz, 8 ears of 7 patients mild hearing loss, 10 ears of 8 patients moderate hearing loss, 3 ears of 3 patients had a moderately-severe hearing loss, and 6 ears of 6 patients had a profound hearing loss. All cases (24 ears of 22 patients) who had a normal four-tone average complained many otologic symptoms other than a hearing loss. CONCLUSION: Blunt head injury is one of the most common causes of the neurologic disorders. It is important to perform thorough assessment of auditory symptoms as soon as possible. Otologic consultation should be sought in all cases for appropriate management.

Role of Toll-like Receptor 2 in a Mouse Model of Allergic Rhinitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Mammalian Toll-like receptors (TLR) participate in innate immune responses to microbial pathogens. Recent interest has been focused on the concept that TLR-induced innate responses can modulate subsequent adaptive immune responses. The objective of this study is to determine whether TLR 2 stimulation in vivo would modulate subsequent allergic responses in an Aspergillus fumigatus (Af) murine model of allergic rhinitis (AR). MATERIALS AND METHOD: Mice were sensitized via intraperitoneal injection with Af antigen and alum, and received a series of three daily intranasal Af antigen challenge. A TLR 2 agonist, PamCys was administrated intranasally one day before sensitization or one day before the first intranasal allergen challenge. Adaptive immune profiles and response to Af challenge were assessed. RESULTS: PamCys decreased the allergen induced nasal recruitment of eosinophils and interleukin (IL)-5 in nasal lavage fluids compared with mice treated with no PamCys. Serologic data revealed that PamCys downregulated Af-specific IgE in the sera of PamCys-treated mice. In addition, spleen cells from the PamCys-treated mice displayed attenuated Af-specific IL-4 and IL-5, but increased interferon (IFN)- and immunosuppressive IL-10. CONCLUSION: The present study demonstrate that TLR 2 agonist decreases allergic responses in this AR model by shifting T helper 2 (Th2) biased immune parameters towards Th1 dominance.

A Case of Fungal Ball of Aspergillus in Chronic Otitis Media / 대한이비인후과학회지

Fungal infections in the ear of immunocompetent patients are mainly observed as otomycosis within the external auditory canal. Benign fungal colonization (fungal ball), though they are common in the paranasal sinuses, has never been reported in the middle ear cavity of a healthy population. We present a case of fungal ball in the middle ear of a 30-year-old, immunocompetent male. He did not have any illness except chronic suppurative otitis media in the right ear. On physical examination, only small central perforation was seen in the right tympanic membrane. Temporal bone computed tomography did not reveal any abnormal finding except thickened tympanic membrane. Intraoperative examination demonstrated a dark gray, cheese-like material in the mesotympanum. After tympanoplasty, mycological staining and histopathologic examination identified the surgical sample to be Aspergillus. So we reported, with a review of literature, the first case of Aspergilloma occurring in the middle ear of a healthy patient.

Neuroimmunological Activation of Afferent Auditory Neural Circuit in LPS-Induced Otitis Media / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES : The goal of this study was to identify the central modulation of the auditory pathway by peripheral inflammation and loud sound exposure, which is associated with proinflammatory cytokines. MATERIALS AND METHOD : Eight male adult Sprague-Dawley rats were exposed to 125-8,000 Hz, 90 dB white noise for three hours. Immediately, 6 hours, 24 hours, and 3 days after the sound stimuli, 2 rats were sacrificed respectively. For the inflammatory stimuli, 10 rats were inoculated with LPS (100 microgram/50 microliter) through ipsilateral tympanic membrane. In 3 hours, 6 hours, 24 hours, 3 days and 7 days, 2 rats were sacrificed respectively. The brains of rats were prepared including the cochlear nucleus and inferior colliculus. The brains were stained for c-fos (proto-oncogene proteins) and IL-1beta. Two normal control rats were sacrificed without treatment. RESULTS : In the noise exposure group, c-fos and IL-1beta were expressed along the previously known auditory neural pathway and some non-hearing-related nuclei. In the LPS injection group, the c-fos and inflammatory cytokine IL-1beta were mainly expressed along the ascending afferent auditory pathway such as cochlear nucleus, trapezoid body, lateral lemniscus, inferior colliculus. IL-1beta expression was also found in the nuclei of non auditory pathway such as locus coeruleus, lateral parabrachial nucleus, and vestibular nucleus. CONCLUSION : These results show that inflammatory reactions of peripheral middle ear cavity and loud sound exposure may induce expression of proinflammatory cytokines along the afferent auditory circuit and the functional auditory pathway. It might be suggested that peripheral changes by inflammation or loud sound could induce functional and physiologic alterations in the auditory system via neuroimmunomodulation.

A Case of Pneumolabyrinth after Temporal Bone Fracture / 대한이비인후과학회지

Pneumolabyrinth or pneumocochlea is an uncommon condition in which the vestibule or cochlea is filled with air. Although there have been several reports about pneumolabyrinth after stapes surgery, it is rarely found in temporal bone fractures. The presence of air inside the inner ear is a definite proof of a pathological connection between the inner ear and the air-filled mastoid or middle ear cavities. We encountered a rare case of a 45-years-old male with a pneumolabyrinth that resulted from a blunt head trauma. A pneumolabyrinth was resolved spontaneously.

Treatment of Cricopharyngeal Dysphagia with Shaker's Head Lift Exercise / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Cricopharyngeal dysphagia refers to the dysfunction of the upper esophageal sphincter complex, which is composed of the cricopharyngeus, inferior pharyngeal constrictor and the upper segment of the cervical esophagus. Adequate relaxation of the cricopharyngeal muscle in conjunction with anterosuperior excursion of the larynx by suprahyoid muscles and propulsion of food bolus are prerequisite for normal swallow, mechanisms of which, if altered, may result in cricopharyngeal dysfunction. Head lift exercise, first described by Shaker, can be utilized in patients with cricopharyngeal dysphagia by strengthening the suprahyoid musculature and reducing the intrabolus pressure. The objective of this study was to introduce Shaker's head lift exercise in the treatment of cricopharyngeal dysphagia patients. SUBJECTS AND METHOD: Two patients suffering from cricopharyneal dysphagia after receiving skull base surgery were managed with Shaker's head lift exercise and the swallowing function was evaluated with videofluoroscopy. RESULTS: Both patients who had been taught how to perform head lift exercise showed improvement in swallowing function as observed with videofluoroscopy. Aspiration disappeared and both patients were able to take oral diet without the aid of gastrostomy tubes. CONCLUSION: Shaker's head lift exercise enabled oral feeding without aspiration in two patients. This demonstrates that Shaker's head lift exercise can be a promising noninvasive treatment modality in the treatment of cricopharyngeal dysphagia.

Long-Term Outcome of the Voice Rehabilitation after Total Laryngectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The voice rehabilitation following total laryngectomy is very important for the quality of life of patients who are cured by cancer treatment. The purpose of this study is to investigate the success rate and complications of various procedures used in our clinics and to evaluate various factors that can affect the success rate of the voice rehabilitation. SUBJECTS AND METHOD: From March 1993 to November 2002, 77 medical charts of the patients who underwent total laryngectomy were reviewed retrospectively to determine the immediate and long-term success rates of voice rehabilitation. The statistic correlation between the variables (age, tumor stage, tumor site, radiotherapy) and the success rate was analysed. RESULTS: Good vocalization was achieved in 90.5% of patients after Provox insertion, 81% after Amatsu procedure, while esophageal voice was acquired by 11.1%. The long-term success rate in 39 patients was 75% in Provox group, 81.8% in Amatsu group and 30.5% in esophageal voice group. There were no statistically significant correlation between the variables and the success rate of vocie rehabilitation. CONCLUSION: The result of this study suggested that tracheoesophageal puncture with Provox prosthesis and Amatsu operation are very effective procedures for the long term voice rehabilitation following total laryngectomy.

Temporal Analysis of Oropharyngeal Swallow in Children / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Studies of normal oropharyngeal swallow in children are essential for the analysis of pediatric dysphagia. The purpose of this study is to define the temporal characteristics of the oropharyngeal swallow in children and to compare these data with young adults. SUBJECTS AND METHOD: This investigation evaluated oropharyngeal swallow physiology during swallows of pudding in 16 children (age 3-13) who had no swallowing complaints including velopharyngeal deficits after surgical treatment of cleft palate and submucous cleft, and 16 normal young adults with no swallowing complaints. temporal analysis of swallow in the children was compared with that of similar temporal measures in the 16 young adults (age 21-29). RESULTS: Temporal measures of pharyngeal swallow events in the children revealed significantly shorter pharyngeal response time, shorter duration of tongue base contact to the posterior pharyngeal wall and longer duration of tongue base posterior movement toward the pharyngeal wall as compared with the normal young adult subjects. CONCLUSION: These differences in the temporal measures of the pharyngeal swallow between children and adults could be the results of differences in the pharyngeal anatomy and the pharyngeal contraction pattern between children and adults. further study of a larger population of normal children is needed.

The Characteristics and the Changes of Tinnitus according to the Recovery of Hearing Loss in the Patients with Sudden Hearing Loss / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Because tinnitus can be generated from the damaged cochlear hair cells, patients with sudden sensorineural hearing loss frequently complain their tinnitus as an important symptom. We prospectively designed this study to understand the clinical characteristics of tinnitus in patients with sudden sensorineural hearing loss. MATERIALS AND METHOD: Thirty-seven patients with sudden sensorineural hearing loss who performed an audiologic study and questionnare of tinnitus before and immediately after the combination therapy for hearing loss were included. Their clinical and audiologic data were prospectively entered into a comprehensive data base to analyze the clinical characteristics of tinnitus. RESULTS: Most of the patients with sudden sensorineural hearing loss showed abrupt and concomitant onset of tinnitus in the same ear of hearing loss. The characteristics of tinnitus were changed according to the degree of hearing recovery of sudden hearing loss. CONCLUSION: Improvement of tinnitus in the patients with sudden sensorineural hearing loss may be closely related to the degree of hearing recovery. Understanding the characteristics of tinnitus in patients with sudden sensorineural hearing loss might be helpful in counselling them during the treatment period of hearing loss.

Two Cases of Hypoglossal Neurilemmoma in the Submandibular Space / 대한이비인후과학회지

Neurilemmomas are tumors arising from the myelin-producing Schwann cells of the peripheral nervous system. Neurilemmomas of the 12th cranial nerve are rare, with most originating intracranially. The rarity of such pathology in the submandibular space makes proper preoperative diagnosis difficult, and is often mistaken to be an inflammatory mass, a malignant lymph node or a salivary gland tumor. The preoperative diagnosis of hypoglossal nerve neurilemmoma in this region is very important in that the patient must be warned of the morbidity of sacrificing the nerve during surgical excision and that the surgeon might be prepared for nerve graft. Therefore, we report recent experience of 2 cases of hypoglossal nerve neurilemmomas occurring in the submandibular area with a review of literature focusing on radiological findings and preoperative differential diagnosis.