Predictors of Early and Late Response to Esomezol and Lifestyle Modification in Adults With Laryngopharyngeal Reflux Disease: A Prospective, Multicenter, Open-Label Cohort Study

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.

Office-Based Injection Laryngoplasty in Patients with High Vagal Paralysis / 대한연하장애학회지

Objective@#High vagal paralysis (HVP) is a type of vocal-fold paralysis, associated with discoordination of the pharyngeal musculature, and the failure of the cricopharyngeus muscle to relax, leading to swallowing disability. We evaluated the difference between the functional results of office-based injection laryngoplasty and medialization thyroplasty in patients with unilateral vocal cord paralysis caused by HVP. @*Methods@#A retrospective review of 28 patients following laryngoplasty with HVP was performed. Pre- and posttreatment swallowing and voice functions were reviewed. @*Results@#Seventeen patients underwent injection laryngoplasties, while 11 received medialization thyroplasties. In both groups, all except one patient who received medialization thyroplasty recovered their ability to swallow after appropriate procedures (100% vs. 91%). An acoustic analysis demonstrated significant changes in shimmer, noiseto-harmonic ratio, and maximum phonation time (MPT) in the injection laryngoplasty group, whereas significant changes in jitter and MPT were observed in the medialization thyroplasty group. @*Conclusion@#Office-based injection laryngoplasty was found to be an effective and reliable therapy for improving swallowing and voice function in patients with HVP, compared to medialization thyroplasty.

Update on Cricopharyngeal Dysphagia / 대한연하장애학회지

Cricopharyngeal dysphagia (CP dysphagia) refers to swallowing difficulties caused by the abnormal movement of the cricopharyngeal muscle, which is part of the upper esophageal sphincter located between the pharynx and the esophagus. The main cause of CP dysphagia is the failure of the cricopharyngeal muscle to relax during swallowing, as a result of which food is unable to pass through the pharynx to the esophagus. Videofluoroscopic swallowing studies and esophageal manometry are the most common methods used for diagnosis. Treatment options include conservative approaches such as postural techniques and swallowing therapy, as well as invasive methods like botulinum toxin injections and surgical procedures. Recent advances in less-invasive treatments such as the botulinum toxin injection have shown success with fewer complications compared to myotomy. However, further research and updates are necessary to provide more effective and safer treatment options for patients with cricopharyngeal dysphagia.

A Case of Severe Dysphagia after Aesthetic Two-Jaw Surgery / 대한연하장애학회지

This study reports a case who presented with swallowing difficulty after orthognathic surgery. A female patient, who had undergone orthognathic surgery for esthetic purpose, presented with dysphagia. Administration of botulinum toxin injection to the cricopharyngeus muscle did not relieve or improve the severe dysphagia. The patient required nasogastric tube feeding for about three months. Swallowing ability was recovered after daily rehabilitation therapy and prescribing pyridostigmine. Injuries to the suprahyoid muscles (involved in laryngeal elevation during the pharyngeal phase of swallowing) during orthognathic surgery, and the inadvertent dissemination of inadequately injected botulinum toxin to adjacent muscles, are possible mechanisms of the severe dysphagia experienced by this patient. The authors also reviewed literature on the prevention and management of dysphagia following the orthognathic surgery.

Risk Factor Analysis of Dysphagia after Oncological Surgery for Patients with Head and Neck Cancer Using a Modified Barium Swallowing Study / 대한연하장애학회지

Objective@#This study evaluated the risk factors for tube feeding dependency of the patients with head and neck squamous cell carcinoma (HNSCC) who underwent an operation with curative intent. @*Methods@#The medical records of patients with HNSCC who underwent operation with curative intent and who also had postoperative MBSS (modified barium swallow study) performed at a single institution were retrospectively reviewed between January 2013 and December 2018. The clinical and oncological characteristics along with the MBS findings and questionnaire results were retrieved. These were used to analyze the potential risk factors for tube feeding dependency after surgery. Univariate analysis of each factor was conducted and the odds ratios were calculated. Additionally, multivariate analysis was performed for the significant factors found on the univariate analysis. @*Results@#60 HNSCC patients (male:female=54:6) with four different primary sites of cancer and who had a mean age of 65.90±11.09 years-old were included in this study. 41 (68.3%) patients were T1-T2, 33 (55%) patients were N+, and 36 (60%) patients were advanced staged (III and IV). 30 (50%) patients received reconstruction with various flaps and 55 (91.7%) patients received neck dissection. Univariate analysis showed a prior history of radiation based therapy and chemoradiation along with silent aspiration, aspiration, pyriform sinus residue, pharyngeal weakness, and high PAS and SPS scores based on MBS showed a significant risk for feeding tube dependency. Multivariate analysis using these factors showed that only the prior history of radiation based therapy and a high SPS score were significant risk factors for feeding tube dependency. @*Conclusion@#Our study showed a 21.7% rate of feeding tube dependency after surgical treatment of HNSCC. A prior history of radiation based treatment and a higher swallowing performance scale score were the significant risk factors for tube feeding dependency.

Current Review of Various Surgical Options for the Treatment of Dysphagia / 대한연하장애학회지

Swallowing is a complex process in which solid or liquid food material is transported from the mouth to the stomach.Dysphagia is a condition characterized by difficulty in the passage of food material along this alimentary tract. Problems related to swallowing can lead to complications such as respiratory infection or even respiratory failure due to aspiration. Malnutrition due to various nutritional deficiencies can also be caused by chronic dysphagia. Hence, adequate timing along with application of proper treatment methods for dysphagia is important. As the pathophysiology of dysphagia is very diverse and complex, a single treatment modality may not be sufficient enough to resolve dysphagia in a patient. Although surgical treatment or instrumental procedures are considered to be invasive, they are the most reliable treatment modality in some cases. The purpose of this article is to review current surgical options in the treatment of dysphagia and to detail surgeons’ perspectives towards the treatment of patients with dysphagia.

The Evaluation of the Short-Term Voice Outcome of Injection Laryngoplasty Using Two Types of Calcium Hydroxylapatite (Radiesse versus Facetem) / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES@#Radiesse® is a widely used calcium hydroxyapatite (CaHA) injection material used for vocal fold injection. Recently, a new CaHA injection material (Facetem ®) which complements the structural disadvantages of Radiesse has been developed and released in the market. The aim of this study is to compare the efficacy and short-term voice outcome of these two CaHA materials.SUBJECTS AND METHOD: A retrospective analysis was performed for 70 patients with unilateral vocal fold paralysis who underwent vocal fold injection using CaHA materials. Acoustic voice analysis, maximal phonation time (MPT), voice handicap index (VHI), and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale were evaluated between Radiesse and Facetem injection group.@*RESULTS@#Both groups showed a signifcant improvement of MPT, VHI, and G, B, A scale after injection. The Facetem group showed similar voice improvement as the Radiesse group, where pre- and postoperatively objective and subjective voice evaluation results were compared.@*CONCLUSION@#Our study reveals that there is no significant difference in efficacy and nor any short-term vocal improvement between Radiesse and Facetem. Therefore, the use of Facetem as CaHA injection material could be considered as an alternative material for patients with unilateral vocal cord paralysis.

The Evaluation of the Short-Term Voice Outcome of Injection Laryngoplasty Using Two Types of Calcium Hydroxylapatite (Radiesse versus Facetem) / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Radiesse® is a widely used calcium hydroxyapatite (CaHA) injection material used for vocal fold injection. Recently, a new CaHA injection material (Facetem ®) which complements the structural disadvantages of Radiesse has been developed and released in the market. The aim of this study is to compare the efficacy and short-term voice outcome of these two CaHA materials. SUBJECTS AND METHOD: A retrospective analysis was performed for 70 patients with unilateral vocal fold paralysis who underwent vocal fold injection using CaHA materials. Acoustic voice analysis, maximal phonation time (MPT), voice handicap index (VHI), and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale were evaluated between Radiesse and Facetem injection group. RESULTS: Both groups showed a signifcant improvement of MPT, VHI, and G, B, A scale after injection. The Facetem group showed similar voice improvement as the Radiesse group, where pre- and postoperatively objective and subjective voice evaluation results were compared. CONCLUSION: Our study reveals that there is no significant difference in efficacy and nor any short-term vocal improvement between Radiesse and Facetem. Therefore, the use of Facetem as CaHA injection material could be considered as an alternative material for patients with unilateral vocal cord paralysis.

Benefits of Palliative Office-Based Hyaluronic Acid Injection Laryngoplasty in Cancer-Related Unilateral Vocal Cord Paralysis Patients

BACKGROUND AND OBJECTIVES: The effect of palliative injection laryngoplasty in cancer-related unilateral vocal cord paralysis patients on voice and swallowing function is uncertain and there are few previous studies of its suitability, benefits as a palliative treatment option. The purpose of this study is to confirm the objective results of voice and swallowing function after palliative office-based hyaluronic acid injection laryngoplasty in cancer-related unilateral vocal cord paralysis patients. MATERIALS AND METHOD: 36 patients who had unilateral vocal cord paralysis from non-thyroidal, extralaryngeal neoplasms were included in this study. To evaluate the clinical outcome, we analyzed perceptual GRBAS grading, acoustic analysis, aerodynamic study, Electroglottography (EGG), Voice Handicap Index (VHI-30) about voice function and disability rating scale (DRS), gastric tube dependency, aspiration pneumonia about swallowing function and 36-Item Short Form Survey version 2 (SF-36v2) about quality of life. RESULTS: In GRBAS scale, G (p < 0.001), R (p=0.004), B (p=0.001), A (p=0.011), and S (p=0.007) showed significant improvement. Jitter, shimmer, speaking fundamental frequency, maximal phonation time, VHI-30, DRS score, gastric tube dependency, aspiration pneumonia, and SF-36v2 were significantly improved after injection (p=0.016, p=0.011, p=0.045, p=0.005, p < 0.001, p < 0.001 p=0.003, p < 0.001, and p < 0.001 respectively). CONCLUSION: From this study we concluded office-based hyaluronic acid injection can be used as a useful palliative treatment option in cancer-related ill patients with unilateral vocal cord paralysis. Palliative hyaluronic acid injection laryngoplasty avoids the need for tube feeding, thus reducing the risk of aspiration pneumonia. These outcomes are accompanied by significant improvement in voice quality.

Laryngeal Verruca Vulgaris: A Case Report and Review of Literature

Verruca vulgaris of the larynx (VVL) is an extremely rare disease that can be easily misdiagnosed as papillary keratosis, squamous papilloma or verrucous carcinoma, which would have led to needless operation. We experienced a case of VVL in a 66-year-old man with 1-year history of progressive hoarseness. Whitish lesions in both vocal cords were observed by using indirect laryngoscopy and completely removed via microlaryngeal surgery with CO2 laser.

Analysis of Dysphagia Patterns Using a Modified Barium Swallowing Test Following Treatment of Head and Neck Cancer

PURPOSE: The purposes of this study were to evaluate specific dysphagia patterns and to identify the factors affecting dysphagia, especially aspiration, following treatment of head and neck cancer. MATERIALS AND METHODS: A retrospective analysis of 57 patients was performed. Dysphagia was evaluated using a modified barium swallow (MBS) test. The MBS results were rated on the 8-point penetration-aspiration scale (PAS) and swallowing performance status (SPS) score. RESULTS: Reduced base of the tongue (BOT) retraction (64.9%), reduced laryngeal elevation (57.9%), and cricopharyngeus (CP) dysfunction (47.4%) were found. Reduced BOT retraction was correlated with clinical stage (p=0.011) and treatment modality (p=0.001). Aspiration in 42.1% and penetration in 33.3% of patients were observed. Twenty-four patients had PAS values over 6, implying aspiration. Forty-one patients had a SPS score of more than 3, 25 patients had a score greater than 5, and 13 patients had a SPS score of more than 7. Aspiration was found more often in patients with penetration (p=0.002) and in older patients (p=0.026). In older patients, abnormal swallowing caused aspiration even in those with a SPS score of more than 3, irrespective of stage or treatment, contrary to younger patients. Tube feeders (n=20) exhibited older age (65.0%), dysphagia/aspiration related structures (DARS) primaries (75.0%), higher stage disease (66.7%), and a history of radiotherapy (68.8%). CONCLUSION: Reduced BOT retraction was the most common dysphagia pattern and was correlated with clinical stage and treatment regimens including radiotherapy. Aspiration was more frequent in patients who had penetration and in older patients. In contrast to younger patients, older patients showed greater risk of aspiration even with a single abnormal swallowing irrespective of stage or treatment.

Characteristics of Adduct Spasmodic Dysphonia and Muscle Tension Dysphonia Using Spectrogram / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Adduct spasmodic dysphonia (ADSD) is a neurogenic and focal laryngeal dystonia resulting in a strained voice quality with spastic voice breaks. While muscle tension dysphonia (MTD) is caused by functional voice disorders, its symptoms are similar to those of ADSD. Because the approaches of treatment for ADSD and MTD are radically different, accurate evaluations are necessary for precise diagnosis. A spectrogram analysis for differentiating ADSD from MTD provides differentiations on four spectral findings (abrupt voice breaks, irregular wide-spaced vertical striations, well-defined formants and high-frequency spectral noise). The aim of this study was to evaluate if the spectrogram could provide detailed information on the visual characteristics that distinguish ADSD and MTD. SUBJECTS AND METHOD: 11 female patients of ADSD and 13 female patients of MTD who were diagnosed by laryngoscope and stroboscope from 2009 through 2012 were selected for this study. The speech samples of subjects were obtained using Computerized Speech Lab. The two speech therapists evaluated a wide-band (300 Hz) spectrogram by blind test using 4 scales (0-3 point) for four spectral findings. RESULTS: Abrupt voice breaks and irregular wide-spaced vertical striations of ADSD were significantly higher than those of MTD. Well-defined formants and high-frequency spectral noise were not found significantly different between two groups. CONCLUSION: The spectrograms provided visual perceptual information needed to differentiate ADSD from MTD. Voice therapy to reduce hypertension could be considered for patients of ADSD with excessive formants and noise. If spectrogram analysis were used along with other assessments, it would be more useful in distinguishing ADSD from MTD.

Effectiveness of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in Patients with Swallowing Disorders -A Systematic Review-

OBJECTIVE: The objective of this systematic review is to evaluate the safety and effectiveness of fiberoptic endoscopic evaluation of swallowing (FEES) for dysphagia patients. METHOD: We performed a systematic review of the literature. We searched Ovid-Medline(R), EMBASE(R) and Cochrane library(R) and Eight domestic databases including KoreaMed up to 19 April 2010. In addition, we added hand search. Searches were conducted without language restriction. We identified ten studies that met our eligibility criteria. Two reviewers independently extracted prespecified data from each study. Also reviewers assessed quality of each study. The qualities of these studies were assessed according to Scottish Intercollegiate Guidelines Network (SIGN) tool. RESULTS: Ten studies (nine diagnostic evaluation studies and one case series) were identified. The complication rate of FEES was 6% which was reported only one study as nose bleeding that did not need further treatment. The effectiveness of FEES was evaluated based on diagnostic accuracy, agreement rate with videofluoroscopy as a reference test. The sensitivities of FEES were 0.87~1.0 (penetration), 0.22~0.96 (aspiration), 0.68~0.91 (pharyngeal residue), and 0.75 (premature spillage) respectively. Specificities of FEES were 0.75~1.0 (penetration), 0.88~1.0 (aspiration), 0.86~1.0 (pharyngeal residue), and 0.56 (premature spillage) respectively. Agreement rate with VFFS were 85~100% (penetration), 82.3~100% (aspiration), 80~89.3% (pharyngeal residues), and 60.7% (premature spillage) respectively. There was no evidence of statistical heterogeneity. The body of evidence as a whole suggests a grade C for FEES. CONCLUSION: FEES is considered as a safe and effective test in patients with dyspahgia and grade C evidence based on existing studies.

Open-Label Observational Study for Evaluating the Short-term Benefits of Rabeprazole Medication on Laryngopharyngeal Reflux

OBJECTIVES: The aims of this study were to determine the benefits of short-term empirical proton pump inhibitor (PPI) medication on laryngopharyngeal reflux (LPR) and to determine whether scores on the reflux symptom index (RSI) and the reflux finding score (RFS) could be combined to identify subgroups of patients that will more likely to improve with this medication. METHODS: Fifty-one Korean Otolaryngology Board-certified specialists joined this prospective, multi-center, and open-label observational study. A total of 1,142 adult patients with LPR was enrolled for 12 weeks of rabeprazol medication. According to pre-treatment scores on RSI and RFS, patients were divided into 4 subgroups. RFS and RSI were measured repeatedly with a month interval along the treatment period. Changes of RSI and RFS were analyzed in an overall study cohort as well as in each subgroup. RESULTS: Approximately 40% (n=455) of enrolled patients were followed up until 12 weeks of PPI treatment. Significant improvement in RSI was obtained in 29%, 58%, and 75% of patients after 4, 8, and 12 weeks of PPI medication. RFS was improved in 16%, 42%, and 57% of the patients with 4, 8, and 12 weeks of PPI medication. All subgroups showed improvement regardless of their pre-treatment scores on the RSI and RFS. CONCLUSION: Even though RSI and RFS may be used as a general guideline for LPR management, pre-treatment RSI and RFS are not useful in predicting the patients' response to short-term PPI medication in the usual pattern of practice for LPR, which is mostly based on the physical evaluation and history taking.

Comparison of Voice Outcomes in Early Glottic Cancer Patients after Laser Surgery or Radiotherapy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Radiotherapy and laser surgery are the main treatment modalities for early glottic cancer. However, which treatment has better voice outcome is unclear. Few studies have considered the effect of radiation dose on voice outcomes after radiotherapy. The purpose of this study was to compare voice outcomes in early glottic cancer patients between two treatment modalities and to identify whether radiation dose affects voice outcomes. SUBJECTS AND METHOD: From January 1995 to December 2010, 66 patients with the early glottic cancer who underwent laser surgery (n=27) or radiotherapy (n=39) were retrospectively investigated. Voice quality was assessed using Computerized Speech Lab and F0, Jitter, Shimmer and noise to harmonic ratio were evaluated. For aerodynamic test, maximum phonation time was also evaluated. RESULTS: F0 differed statistically between the laser surgery group and radiotherapy group. In laser surgery group, F0 was elevated after surgery. On the other hand, F0 decreased statistically after radiotherapy. In the radiotherapy group, the dose was statistically different between the lower and higher dose groups. In T2 stage disease, which received a higher radiation dose, voice outcomes were poorer than in T1a or T1b stage diseases. CONCLUSION: In early glottic cancer, F0 differed statistically between the laser surgery group and the radiotherapy group: F0 decreased statistically after radiotherapy. In the radiotherapy group, voice quality was affected by radiation dose as the higher dose resulted in poorer voice outcomes.

Office-Based Laryngoesophageal Procedure / 대한이비인후과학회지

Office-based procedures of laryngoesophageal region have become significantly more common in recent years. The term "office-based" refers to an awake patient in an upright position, typically with no sedation and receiving local topical anesthesia alone. The goal of this article is to introduce various recent office-based laryngological procedures, including diagnosis and treatment and to review of literatures along with our experiences. The authors hope that this document will encourage otolaryngologists to expand the role of office-based diagnosis and treatment in laryngology for the best treatment of their patients' care.

Rehabilitation Protocol for Postoperative Dysphagia in Head and Neck Cancer Patients / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Treatment of head and neck cancer patients with surgical removal may result in some degree of dysphagia. Swallowing disorders depend on the site, the extent of surgical resection, and the nature of the surgical reconstruction. As a result, rehabilitation needs to be managed by head and neck surgeons with specific anatomical knowledge. However, in Korea, only occupational therapists can get approval for dysphagia rehabilitation from the national health insurance cooperation. Therefore, we designed a Advanced Rehabilitation Protocol (ARP) rehabilitation and carried out a comparative study against the current rehabilitation protocol. SUBJECTS AND METHOD: Data were collected by reviewing medical records of 40 patients who received operation on oral cavity, larynx and hypopharynx from November 2007 to January 2009. Of these, 20 patients were treated with ARP under the management of head and neck surgeons but the other 20 patients were not. RESULTS: Although the results had no statistical significance, the study showed that ARP had the effect of shortening the rehabilitation and enabled them to start adjuvant therapies early. CONCLUSION: Rehabilitation needs to be managed cooperatively by a multidisciplinary team that includes an otolaryngologist who has specific anatomical knowledge of the concerned area and reconstruction according to specific swallowing problems.

A Case of Spontaneous Extracapsular Hemorrhage of Intrathyroidal Parathyroid Adenoma / 대한이비인후과학회지

Intrathyroidal parathyroid adenoma is an infrequent lesion which can be explained by abnormalities during embryonic migration of the parathyroid glands. Extracapsular hemorrhage from a intrathyroidal parathyroid adenoma is extremely rare, however, due to its location near upper airway, it might cause a life-threatening situation. Therefore, if patients presented with anterior neck painful swelling, skin ecchymosis associated with dysphagia and/or hoarseness, extracapsular hemorrhage from parathyroid adenoma should be considered as a possible diagnosis. Estimation of serum calcium level is essential as the presence of hypercalcemia can help to make the diagnosis pre-operatively. As rupture of a parathyroid adenoma and cyst may lead to local dissemination of tumor cells and an increased risk of recurrent hyperparathyroidism, careful longterm follow-up is required. We report an unusual case of spontaneous rupture of intrathyroidal parathyroid adenoma with a review of literature.

Analysis of Influencing Factors on Cervical Lymph Node Metastasis in Early Oral Tongue Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The status of cervical lymph node metastasis has a greatinfluence on the prognosis of patients with early oral tongue cancer. We evaluated various clinical, histopathological, lymphangiogenic parameters and their association with cervical lymph node metastasis in early oral squamous cell carcinoma of the tongue. SUBJECTS AND METHOD: Fifty-one patients with squamous cell carcinoma of the early oral tongue were classified as their tumor stage, lymph node metastasis, histopathological grade, tumor depth of invasion and their paraffin-embedded surgical specimens were investigated by immunohistochemical analysis using VEGF and E-cadherin antibody. RESULTS: Cervical lymph node metastases were present in 18 of the 51 cases (35.3%). Regarding tumor cell differentiation, there were 28 (54.9%), 19 (37.3%), and 4 (7.8%) well-, moderate-, and poorly-differentiated cases, respectively. The depth of invasion varied from 1 to 25 mm and averaged 9.69+/-5.83 mm, and there was a significant correlation between the tumor depth ofinvasion and cervical lymph node metastasis (p<0.001) and primary tumor size (p<0.001). Immunohistochemical analysis showed the expression rates of VEGF, E-cadherin as 46.9% and 52.9%, respectively. There was significant correlation between the expressions of VEGF and lymph node metastasis (p=0.009). Patients who were followed up for more than 12 months had a 5-year overall survival of 82%. Primary tumor size and VEGF expression was associated with the overall survival. CONCLUSION: The analysis of these clinical, histological, and immunohistochemical parameters may help to identify patients who would benefit from a neck dissection by predicting the likelihood of cervical lymph node metastasis.

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