Clinical Practice Guideline: Clinical Efficacy of Nasal Surgery in the Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians’ grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians’ care based on their experience and assessment of individual patients.

Weight Loss for Obstructive Sleep Apnea: Pharmacological and Surgical Management

Obstructive sleep apnea (OSA) is a relatively common sleep disorder characterized by repetitive narrowing or obstruction of the upper airway, including the nasal cavity, pharynx, and larynx, during sleep. OSA can cause a variety of symptoms and/or complications, such as excessive daytime sleepiness, reduced concentration, hypertension, type II diabetes, and stroke. Accordingly, an accurate diagnosis and appropriate treatments are required for OSA. Obesity is an important risk factor for OSA and is characterized by the abnormal accumulation of fat in the body, including the upper airway. When the body weight increases, adipose tissue accumulates in the pharynx, which can narrow the diameter of the upper airway and lead to dysfunction of the pharynx dilator muscles. These changes caused by weight gain can cause or exacerbate OSA. Various therapeutic options exist for patients with overweight or obesity, including diet, behavioral modifications, exercise, pharmacological treatments, and surgical procedures. Of these, diet, behavioral modifications, and exercise constitute the first-line management for obesity. However, their results are relatively unsatisfactory, and pharmacotherapy and bariatric surgery are generally implemented in obese patients with OSA. Therefore, the purpose of this paper is to review pharmacological and surgical management strategies for obesity that are currently commonly used in overweight or obese adult patients with OSA.

Trends in Palate Surgery for Obstructive Sleep Apnea in Korea Over the Past 12 Years

Background and Objectives@#In the past, palate surgery, such as uvulopalatopharyngoplasty (UPPP), was widely performed to treat obstructive sleep apnea (OSA). However, since the introduction of reimbursement for positive airway pressure (PAP) therapy in 2018, it is believed that the frequency of these operations has significantly declined. Despite this, there are currently no definitive data to support this assertion. @*Methods@#We examined the number of palate operations conducted by utilizing medical statistical data from the Health Insurance Review and Assessment Service (HIRA) Bigdata Open portal. Within this system, we queried UPPP (Q2196), UPPP_complex (Q2195), and uvulectomy (Q2197), and collected data spanning from 2010 to 2021. The data were then analyzed according to hospital type, sex, and age groups. @*Results@#In total, 2,728 palate operations were performed in 2010; this number peaked at 4,330 cases in 2014, and then steadily decreased to 3,096 cases in 2021. Of the operations in 2010, 1,892 were conducted in general hospitals, while 836 took place in primary hospitals and clinics. However, by 2021, the number of operations performed in general hospitals had decreased to 1,002, while those performed in primary hospitals and clinics had increased to 2,093. The most common age group for these operations was 30–39 for men and 40–49 for women. Since 2019, the proportion of palate operations relative to the number of OSA patients has decreased. @*Conclusion@#The frequency of palate surgery in Korea started to decrease after 2014. Despite this, there was an increase in the number of these operations performed in hospitals and clinics, with middle-aged patients being the primary recipients. The ratio of palate operations to OSA patients has shown a notable decrease after the introduction of reimbursement of polysomnography and PAP therapy.

Clinical Practice Guideline: Nasal Irrigation for Chronic Rhinosinusitis in Adults

The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.

Ocular and Facial Herpes Zoster and Meningitis in an Adult after Zoster Vaccination

Purpose@#To report a case of ocular and facial herpes zoster and meningitis after herpes zoster vaccination.Case summary: A 60-year-old man was administered Zostavax® on his left arm; he developed a vesicular rash over his left eye and forehead 4 days afterwards. He started antiviral drugs for the rash, and visited the hospital for severe headache and spread of the rash to involve the tip of his nose, face, and palate by day 7. He was taking Synthyroid® (Bukwang Pharmaceuticals, Seoul, Korea) since his thyroidectomy for thyroid cancer 6 years ago. He had never been diagnosed with chickenpox, but had an episode of red facial rash in childhood. Slit-lamp examination revealed conjunctival chemosis, hyperemia, and a pseudodendrite in the peripheral cornea. The anterior chamber was quiet, and there were no significant findings on his brain magnetic resonance imaging. Varicella zoster virus was detected in the cerebrospinal fluid by polymerase chain reaction. The patient was treated with oral acyclovir drugs and topical ganciclovir, levofloxacin, and bromfenac. One week later, the pseudodendrite disappeared and conjunctival chemosis improved. There was no recurrence during 6 months follow-up. @*Conclusions@#Reactivation of ocular or facial herpes zoster or meningitis after zoster vaccination may occur, rarely. Immediate antiviral treatment is required in these cases.

Changes in the Glaucoma Diagnosis during the Last 10 years: Health Insurance Review and Assessment Service Data 2010-2019

Purpose@#We determined the current status of glaucoma diagnoses in Korea and trends in the change over the past 10 years using data from the Health Insurance Review and Assessment Service. @*Methods@#The glaucoma diagnostic code was collected from the disease subclass statistics of the medical statistical information disclosed in the Healthcare Bigdata open system, and the number of health insurance patients who were billed for medical care benefit costs from 2010 to 2019 with the glaucoma diagnosis code was collected. Data were collected for each diagnostic code by dividing it by year, age group, and gender, and then changes in the current status of glaucoma diagnosis per 100,000 people were analyzed by age group. A joinpoint regression analysis was used to determine the increasing and decreasing trends for each diagnostic code and whether the trend changed during the study period. @*Results@#The number of health insurance patients who received treatment with the glaucoma diagnostic code in 2019 compared to 2010 increased by 120.3% and 109.5% per 100,000 people covered by medical care. This increasing trend has slowed as of 2015. Suspected glaucoma, primary open-angle glaucoma, and primary angle-closure glaucoma showed an increasing trend, while glaucoma secondary to eye trauma and glaucoma secondary to drugs declined markedly. No significant trend in glaucoma secondary to eye inflammation was detected, and glaucoma secondary to other eye disorders and unspecified glaucoma tended to increase. Other glaucoma diagnoses decreased from 2010 to 2012 and then increased. @*Conclusions@#The number of patients who underwent glaucoma treatment among all health insurance patients increased significantly from 2010 to 2019. Despite the overall increasing trend, eye trauma and drug-induced secondary glaucoma have markedly decreased.

Changes in the Glaucoma Diagnosis during the Last 10 years: Health Insurance Review and Assessment Service Data 2010-2019

Purpose@#We determined the current status of glaucoma diagnoses in Korea and trends in the change over the past 10 years using data from the Health Insurance Review and Assessment Service. @*Methods@#The glaucoma diagnostic code was collected from the disease subclass statistics of the medical statistical information disclosed in the Healthcare Bigdata open system, and the number of health insurance patients who were billed for medical care benefit costs from 2010 to 2019 with the glaucoma diagnosis code was collected. Data were collected for each diagnostic code by dividing it by year, age group, and gender, and then changes in the current status of glaucoma diagnosis per 100,000 people were analyzed by age group. A joinpoint regression analysis was used to determine the increasing and decreasing trends for each diagnostic code and whether the trend changed during the study period. @*Results@#The number of health insurance patients who received treatment with the glaucoma diagnostic code in 2019 compared to 2010 increased by 120.3% and 109.5% per 100,000 people covered by medical care. This increasing trend has slowed as of 2015. Suspected glaucoma, primary open-angle glaucoma, and primary angle-closure glaucoma showed an increasing trend, while glaucoma secondary to eye trauma and glaucoma secondary to drugs declined markedly. No significant trend in glaucoma secondary to eye inflammation was detected, and glaucoma secondary to other eye disorders and unspecified glaucoma tended to increase. Other glaucoma diagnoses decreased from 2010 to 2012 and then increased. @*Conclusions@#The number of patients who underwent glaucoma treatment among all health insurance patients increased significantly from 2010 to 2019. Despite the overall increasing trend, eye trauma and drug-induced secondary glaucoma have markedly decreased.

A Rare Case of Synchronous Pleomorphic Adenoma and Lobular Capillary Hemangioma of Nasal Septum / 대한이비인후과학회지

Pleomorphic adenoma is the most common benign tumor of major salivary gland, but it rarely originates from the nasal cavities. Meanwhile, the lobular capillary hemangioma, known as pyogenic granuloma, is also a benign tumor of unclear etiology unusually found in the sinonasal area. Little is known about cases where pleomorphic adenoma and lobular capillary hemangioma originate simultaneously in the nasal cavity. Here, we report a case of 63-year-old female with pleomorphic adenoma and lobular capillary hemangioma simultaneously arising from the nasal septum. After endoscopic tumor resection, there was no recurrence or complication during the follow-up.

Positive Airway Pressure Prescription and Management for Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is characterized by repeated events of complete or partial upper airway obstruction during sleep and is a chronic sleep disorder that requires long-term comprehensive management. Positive airway pressure (PAP) is recommended for treatment of OSA in adults with excessive daytime sleepiness, decreased sleep-related quality of life, and comorbid hypertension. During PAP therapy, regular follow-up is continuously necessary to evaluate side effects or complications, compliance, and treatment effects such as OSA-related symptoms, quality of life, and consequences. This review provides knowledge about PAP-related background information, indications for PAP prescription including the Korean National Health Insurance criteria, optimal pressure, PAP modes, patient education and support, short-term and long-term management, interpretation of PAP uses, and alternative therapies.

The Association between Low Vitamin D Status and Autoimmune Thyroid Disease in Korean Premenopausal Women: The 6th Korea National Health and Nutrition Examination Survey, 2013–2014 / 가정의학회지

BACKGROUND: This study aimed to analyze the association of low vitamin D status with thyroid autoimmunity and dysfunction in the Korean population according to sex and menopausal status in women. METHODS: This study was based on the data acquired from the 6th Korea National Health and Nutrition Examination Survey. We enrolled 4,356 subjects who had data of thyroid function, antithyroid peroxidase antibody (TPOAb), and serum 25-hydroxyvitamin D (25[OH]D) levels. We excluded subjects who were pregnant and who had a history of thyroid disease or thyroid cancer, and those with transient thyroid dysfunction who tested negative for TPOAb (TPOAb[−]). RESULTS: TPOAb positivity (TPOAb[+]) with thyroid dysfunction (subclinical and overt hypothyroidism) was more prevalent in the vitamin D deficient group than in the vitamin D insufficient and sufficient groups including premenopausal (P=0.046) and postmenopausal women (P=0.032), although no significant differences were observed in men. The mean serum 25(OH)D level was significantly lower in the TPOAb(+) with thyroid dysfunction group than in the TPOAb(+) with euthyroidism and TPOAb(−) groups of premenopausal women (P=0.001), although no significant differences were observed in men and postmenopausal women. Multivariate binary logistic regression analysis, adjusted for age, body mass index, and current smoking status, showed that vitamin D insufficiency and deficiency were significantly associated with TPOAb(+) with thyroid dysfunction in premenopausal women (P<0.001), although no significant associations were observed in men and postmenopausal women. CONCLUSION: Low vitamin D status was significantly associated with thyroid autoimmunity and dysfunction in the Korean population, especially in premenopausal women.

Association between Alcohol Consumption and Mental Health (Perceived Stress, Depressive Mood, Suicidal Ideation, Quality of Life) in Koreans: The Sixth Korean National Health and Nutrition Examination Survey in 2015

BACKGROUND: Causal hypotheses suggest that alcohol-related disorders may also cause psychiatric disorders and problems, or vice versa. The association between alcohol consumption and mental health is important from both research and therapeutic viewpoints. Therefore, we aimed to analyze the association between alcohol consumption and mental health (perceived stress, depressive mood, suicidal ideation, quality of life) in Korean adults over 19 years old.METHODS: We finally included 5,399 adults who had participated in the Korean National Health and Nutrition Examination Survey in 2015, and analyzed the association between alcohol consumption and mental health, using logistic regression.RESULTS: Perceived stress was associated with alcohol consumption in problem drinkers (odds ratio [OR]=1.35, 95% confidence interval [CI]=1.13–1.61). Depressive mood was associated with alcohol consumption in moderate and problem drinkers (OR=0.90, 95% CI=0.71–1.11 and OR=1.35, 95% CI=1.06–1.70, respectively). Suicidal ideation was not associated with alcohol consumption in moderate and problem drinkers (P=0.063 and P=0.068, respectively). Quality of life was associated with alcohol consumption in moderate and problem drinkers (OR=0.48, 95% CI=0.41–0.57 and OR=0.77, 95% CI=0.66–0.92, respectively).CONCLUSION: We found that moderate drinkers have a lower risk of depressive mood and a higher quality of life as compared to low drinkers. However, problem drinkers have a higher quality of life but a higher risk of perceived stress and depressive mood as compared to low drinkers.

The Association between Low Back Pain and Mental Health in Korean Adults Over the Age of 50: Korean National Health and Nutrition Examination Survey, 2013

BACKGROUND: Lower back pain (LBP) is the most common musculoskeletal disease in adults over the age of 50. LBP is associated with physical activity and mental health such as depression or suicidal thoughts. We aimed to analyze the association between LBP and mental health and that between physical activity and depressive mood in LBP patients among Korean adults over the age of 50.METHODS: We included 2,681 adults in the analysis, who participated in the 2013 Korean National Health and Nutrition Examination Survey, and used a t-test, logistic regression analysis, and chi-squared test via complex sampling. We analyzed the association between LBP and mental health, various kinds of physical activity, and depressive mood after adjusting for confounding factors.RESULTS: Poor mental health (perception of stress, diagnosis of depression, depressive mood, suicidal thoughts, and suicide attempts) were significantly associated with LBP. The LBP group was 2.077 times more likely to be diagnosed with depression and was 4.666 times more likely to have suicidal thoughts than the control group. Exercise, such as walking, was associated with a reduced risk of depressive mood in subjects with LBP.CONCLUSION: LBP patients were at high risk of being diagnosed with depression, experiencing suicidal thoughts and depressive mood, and attempting suicide. In LBP patients, walking was associated with a reduced depressive mood.

Association between Hyperuricemia and Health-Related Quality of Life in Korean Adults: Based on the Seventh Korean National Health and Nutrition Examination Survey (2016–2017)

BACKGROUND: The prevalence of hyperuricemia has increased over the past few decades. Hyperuricemia is responsible for the increased risk of hypertension, type 2 diabetes mellitus, chronic renal disease, and cardiovascular disease. Health-related quality of life (HQoL) has been increasingly used as an outcome in clinical trials, effectiveness research, and research on quality of care. Therefore, we aimed to analyze the association between hyperuricemia and HQoL in Korean adults aged >19 years.METHODS: We included 2,376 male and 2,593 female who participated in the Korea National Health and Nutrition Examination Survey from 2016 to 2017. Hyperuricemia was defined as a serum uric acid (SUA) level of 7 mg/dL. The Euro quality of life-5 dimension (EQ-5D) questionnaire was used to measure HQoL. A multiple logistic regression analysis was performed to examine the association between hyperuricemia and HQoL.RESULTS: The EQ-5D index score of the hyperuricemia group was significantly lower than of the healthy group. After adjusting for multiple covariates, the odds ratio (95% confidence interval, [CI]) for mobility issues was 1.46 (95% CI, 1.211–1.683) in male and 1.33 (95% CI, 0.716–2.464) in female; however, the difference was not statistically significant for female.CONCLUSION: Hyperuricemia was associated with reduced quality of life. It is important to control SUA levels to improve HQoL.

Epithelial-Myoepithelial Carcinoma of the Inferior Turbinate: A Case Report

Case of a 19-Year-Old Male with Nocturnal Groaning (Catathrenia) / 수면정신생리

Catathrenia is a rare sleep disease characterized by monotonous groaning sounds that appear to be related with prolonged expiration, commonly experienced during rapid eye movement (REM) sleep. Catathrenia is also known as nocturnal groaning or sleep-related groaning and is currently categorized as a sleep-related breathing disorder. We present a rare case of a 19-year-old male with nocturnal groaning during non-REM sleep. We suggest that if catathrenia is suspected, polysomnography should be utilized to differentiate it from various sleep disorders such as snoring, central sleep apnea, sleep talking, parasomnia, and sleep-related movement disorders.

Anthropometric Characteristics of Korean Patients with Obstructive Sleep Apnea

BACKGROUND AND OBJECTIVES: Obesity is one of the most important risk factors for obstructive sleep apnea (OSA). There is limited evidence regarding the obesity-related anthropometric characteristics of Korean patients. MATERIALS AND METHOD: Medical records of 984 patients referred to 3 tertiary referral hospitals for habitual snoring or sleep apnea were analyzed. We defined OSA as apnea-hypopnea index (AHI) ≥5 and analyzed data to determine the anthropometric characteristics of patients with OSA such as neck circumference (NC), waist circumference (WC), hip circumference (HC), and waist to hip ratio (WHR). RESULTS: A total of 952 patients (719 men) were included in the analysis. The main findings were: 1) BMI, WC, NC, HC, and WHR were greater among patients with OSA than among controls (AHI 50 years; 3) WC and WHR were most strongly correlated with AHI for men and women, respectively. CONCLUSION: OSA is associated with anthropometric characteristics, although different patterns were observed between men and women. OSA was more strongly associated with NC or WC among men and with WHR among women.

Scoring Methods of Polysomnography for Diagnosis of Sleep Apnea in Adolescents / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Respiratory scoring guidelines for children and adults have been used for evaluating adolescents both in the 2007 and 2012 American Academy of Sleep Medicine (AASM) scoring manuals. We compared the scoring methods of polysomnography used in these scoring manuals, where pediatric and adult scoring rules were adopted for the diagnosis of sleep apnea in adolescents. SUBJECTS AND METHOD: 106 Korean subjects aged between 13 and 18 years were enrolled. All subjects underwent overnight polysomnography in a sleep laboratory. Data were scored according to both pediatric and adult guidelines in the 2007 and 2012 AASM scoring manuals. RESULTS: Both pediatric and adult apnea hypopnea index (AHI) using the 2012 method were significantly higher than those using the 2007 method. The difference in AHI compared between pediatric and adult scores with the 2012 AASM scoring system was markedly decreased from that with the 2007 method. There was a significant discordance in sleep apnea diagnosis between pediatric and adult scoring rules in the 2012 method. CONCLUSION: Both pediatric and adult rules were used for the diagnosis of adolescent sleep apnea in the 2012 method. However, there was significant discordance in the diagnosis between pediatric and adult scoring guidelines in the 2012 AASM manual, probably due to different cut-off values of AHI for the diagnosis of sleep apnea in pediatric (≥1) and adult (≥5) patients. Further studies are needed to determine a more reasonable cut-off value for the diagnosis of sleep apnea in adolescents.

Nasal Hump Correction Using Modified Autospreader Graft: Report of Two Cases / 대한이비인후과학회지

It is common to find a nose with a hump, lower nasal tip and a radix among Koreans. A common procedure as an aesthetical improvement for such feature, involves rasping of the hump, while lifting the tip and the bridge at the same time. As for the hump, en bloc resection is a well-known, traditional surgical method, but it may cause an open roof deformity, which leads to a high possibility of infection if dorsal augmentation using silicone was performed through it as it connects the nasal cavity and dorsum. To overcome this complication, the hump on the bony portion and cartilaginous has been improved by a modified autospreader graft. Also, the graft can also be used for tip-plasty in dorsal augmentation using silicone, septal extension graft, strut and onlay graft. As a result of constant monitoring for a year, the reformation of the hump and infection was not found.

Effect of Non-Steroidal Anti-Inflammatory Drug Mouthwash on Post-Tonsillectomy Pain: Randomized, Controlled Study / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Altough tonsillectomy is one of the most common otolaryngological procedures, a highly reliable and effective method for reducing postoperative pain has yet to be identified. This study evaluated the efficacy of a non-steroidal anti-inflammatory drug (NSAID) mouthwash on postoperative pain in tonsillectomy patients. SUBJECTS AND METHOD: A total of 64 patients who underwent tonsillectomy were randomly assigned to one of two groups (32 patients each). One group received the NSAID mouthwash and the other a distilled water mouthwash. Postoperative pain in the two groups was compared by assessing pain severity 1-9 days postoperatively using a visual analog scale. RESULTS: Compared to the distilled water mouthwash group, patients using the NSAID mouthwash showed a statistically significant decrease in postoperative pain over the first 9 postoperative days. CONCLUSION: A NSAID mouthwash may be a simple and effective method for controlling post-tonsillectomy pain when administered in conjunction with routine medications.

Changes of Sleep Disordered Breathing and Quality of Life after Adenotonsillectomy in Pediatric Obstructive Sleep Apnea / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Pediatric obstructive sleep apnea (OSA) can have an effect on the quality of life (QOL) such as behavior, school performance, emotional distress and daytime function. We aim to verify changes in sleep disordered breathing based on polysomnographic findings and disease specific health related QOL before and after adenotonsillectomy in Korean children with OSA. SUBJECTS AND METHOD: A total 20 children aged 3 through 13 years old (mean age=6.7 years old and male/female=14/6) with OSA were included. We evaluated respiratory disturbances in patients using the standard polysomnography and the OSA-specific health related QOL based on Korean Obstructive Sleep Apnea-18 Survey (KOSA-18). RESULTS: There were significant improvements in apnea-hypopnea index (from 9.4±7.4 to 1.1±0.8 events/hour, p<0.001) and total score of KOSA-18 (71.3±26.0 to 33.6±10.7, p<0.001) after adenotonsillectomy. CONCLUSION: Sleep disordered breathing and QOL improve significantly after adenotonsillectomy in Korean OSA children.