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.

KAAACI Allergic Rhinitis Guidelines: Part 1. Update in pharmacotherapy

The prevalence of allergic rhinitis (AR) and the socioeconomic burden associated with the medical cost and quality of life of AR have progressively increased. Therefore, practical guidelines for the appropriate management of AR need to be developed based on scientific evidence considering the real-world environment, values, and preferences of patients and physicians. The Korean Academy of Asthma, Allergy and Clinical Immunology revised clinical guidelines for AR to address key clinical questions of the management of AR. Part 1 of the revised guideline covers the pharmacological management of patients with AR in Korea. Through a meta-analysis and a systematic review, we made 4 recommendations for AR pharmacotherapy, including intranasal corticosteroid (INCS)/intranasal antihistamine combination therapy, oral antihistamine/INCS combination therapy, leukotriene receptor antagonist treatment in AR patients with asthma, and prophylactic treatment for patients with pollen-induced AR. However, all recommendations are conditional because of the low or very low evidence of certainty. Well-designed and strictly executed randomized controlled trials are needed to measure and report appropriate outcomes.

KAAACI Allergic Rhinitis Guidelines: Part 2. Update in nonpharmacotherapy

Allergic rhinitis is the most common chronic disease worldwide. Various upper airway symptoms lower quality of life, and due to the recurrent symptoms, multiple treatments are usually attempted rather than one definitive treatment. There are alternatives to medical (medication-based) and nonmedical treatments. A guideline is needed to understand allergic rhinitis and develop an appropriate treatment plan. We have developed guidelines for medical treatment based on previous reports. The current guidelines herein are associated with the “KAAACI Evidence-Based Guidelines for Allergic Rhinitis in Korea, Part 1: Update in pharmacotherapy” in which we aimed to provide evidence-based recommendations for the medical treatment of allergic rhinitis. Part 2 focuses on nonpharmacological management, including allergen-specific immunotherapy, subcutaneous or sublingual immunotherapy, nasal saline irrigation, environmental management strategies, companion animal management, and nasal turbinate surgery. The evidence to support the treatment efficacy, safety, and selection has been systematically reviewed. However, larger controlled studies are needed to elevate the level of evidence to select rational non-medical therapeutic options for patients with allergic rhinitis.

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.

Utilization and Application of Modified Action Camera in Otorhinolaryngoloic Surgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: In recent years, surgical imaging has become important for legal and educational purposes. Significant improvements can be made from the surgeon's point of view in recording surgical procedures, particularly with respect to the action camera with high-definition video recordings. For otolaryngologic surgery, the surgical view is narrow, and there is a limit to proper imaging using the existing lens of the action camera. Therefore, we aimed to find out if we could obtain surgical images through simple modification of action camera. MATERIALS AND METHOD: The action camera was modified to match the surgical field. We selected a suitable lens for otolaryngology surgery using a calculation formula. The action camera was simply modified according to the design. The modified action camera can be mounted on the surgeon's head or the surgical light. We compared the images taken with the modified action camera and the images taken with the existing camcorder. The modified action camera was able to capture a narrow surgical field for otolaryngologic surgery. RESULTS: Unlike the existing method, we were able to obtain high-quality images using a modified action camera at the first person's viewpoint without auxiliary manpower. The action camera was considerably cost effective compared to other methods of recording surgery. CONCLUSION: The modified action camera allows for high-definition, cost-effective, and firstperson viewpoint for otolaryngologic surgery. The modified action camera allows for detailed videography that can enhance surgical teaching, presentation and patient education materials.

Comparing the Effectiveness of Olfactory Training, According as Type and Preference of Odorant

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.

Guidelines for the Antibiotic Use in Adults with Acute Upper Respiratory Tract Infections / 감염과화학요법

These guidelines were developed as part of the 2016 Policy Research Servicing Project by the Korea Centers for Disease Control and Prevention. A multidisciplinary approach was taken to formulate this guideline to provide practical information about the diagnosis and treatment of adults with acute upper respiratory tract infection, with the ultimate aim to promote the appropriate use of antibiotics. The formulation of this guideline was based on a systematic literature review and analysis of the latest research findings to facilitate evidence-based practice, and focused on key questions to help clinicians obtain solutions to clinical questions that may arise during the care of a patient. These guidelines mainly cover the subjects on the assessment of antibiotic indications and appropriate selection of antibiotics for adult patients with acute pharyngotonsillitis or acute sinusitis.

Radiological Examinations of Inferior Turbinate in Patients with or without Deviated Nasal Septum by Using Computed Tomography / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to analyse the radiological anatomic dimensions of the inferior turbinate in patients without deviated nasal septum and compare it to those in the patients with deviated nasal septum using computed tomography. SUBJECTS AND METHOD: The OMU CTs of 98 patients, 196 nostrils with or without deviated nasal septum were evaluated (control group: 42 patients, deviated septum group: 56 patients). The analysis of the CT scans contained the mucosal and bony length, mucosal width of the turbinate and the anterior and posterior mucosal overlay. And also evaluated the cross-sectional area and the type of inferior turbinate bone. RESULTS: All subjects were divided into three groups: the concave, convex, and control groups. The correlations of fifteen measuring points such as anterior, middle and posterior medial mucosal thickness, total width, bone width, medial mucosa width of inferior turbinate, and area of inferior turbinate bone were significantly different among the groups (concave side>con-trol group>convex side). Of the demographic factors, age was negatively correlated with mucosa and bone length. Types of inferior turbinate bone were as follows: lamella type (38%), combined type (37%), compact type (25%). CONCLUSION: There were statistical differences in some measured anatomical points among the concave, convex, and control groups. Greater septum deviation was correlated with greater degree of hypertrophysm of the inferior turbinate. The age of patients showed negative correlation with inferior turbinate length. Most frequent type of inferior turbinate was lamella type. The results of this study may provide important information when considering turbinate surgery.

Alternative Method for Primary Nasal Epithelial Cell Culture Using Intranasal Brushing and Feasibility for the Study of Epithelial Functions in Allergic Rhinitis

PURPOSE: Although differentiated normal human nasal epithelial (NHNE) cells can be used to study the role of human nasal epithelium, there is a need for effective culture models of nasal epithelium in sinonasal disease status, including allergic rhinitis (AR). We aimed to examine the feasibility of intranasal brushing for culture of nasal epithelial cells in AR patients and to verify the hypothesis that allergic nasal epithelial (ARNE) cells differ in histologic and physiologic characteristics. METHODS: We established a system for isolating (via intranasal brushing) and culturing (with air-liquid interface, ALI) nasal epithelial cells from healthy volunteers (n=8) and AR patients (n=8). We used this system to compare the histologic findings and physiologic characteristics of NHNE and ARNE. RESULTS: The histology results showed that fully differentiated ALI culture was obtained at least 14 days after confluence and that both ciliated and secretory cells were well differentiated in ALI culture using nasal brushing. The histology results of ARNE culture were significantly different from NHNE. The number of ciliated cells was lower, and secretory cells were more dominant in ARNE cell culture compared to NHNE cells. We also observed, by electron microscopy, loose tight junctions and short cilia in cultured ARNE cells. In addition, the mRNA level of TSLP which was one of the epithelial-derived allergic cytokines was significantly higher, and the expressions of genes involved in ciliogenesis were lower in cultured ARNE cells without allergen stimulation. CONCLUSIONS: Our findings suggest that ALI culture of ARNE cells using intranasal brushing may be an alternative method for epithelial cell culture in AR patients and that cultured ARNE cells will be useful for in vitro studies of the mechanisms at play during AR because they maintain unique allergic characteristics.

The time-course and RNA interference of TNF-alpha, IL-6, and IL-1beta expression on neuropathic pain induced by L5 spinal nerve transection in rats / 대한마취과학회지

BACKGROUND: The objective of this study was to investigate the time-course of the expression of TNF-alpha, IL-6, and IL-1beta after L5 spinal nerve transection (SNT), and to determine the effect of small interfering RNA (siRNA) targeting these cytokines on neuropathic pain. METHODS: Rats received control siRNA (CON group, n = 80) or a cocktail of siRNAs targeting these cytokines (COCK group, n = 70). The siRNAs were given via intrathecal catheter 1 d prior to SNT, on the operation day, and 1, 2 and 3 d postoperatively. Behavioral tests and levels of the cytokine mRNAs and proteins as well as glial cell activity were following the L5 SNT. RESULTS: In the CON group, TNF-alpha and IL-1beta mRNA levels increased immediately after SNT and remained high for 6 d, while IL-6 transcripts only began to increase after 12 h. TNF-alpha and IL-1beta mRNA levels in the COCK group were lower than in the CON group at all time points (P < 0.05). In the behavioral tests, allodynia and hyperalgesia were significantly lower in the COCK group from 2 d after SNT (P < 0.05). CONCLUSIONS: The time courses of TNF-alpha, IL-6 and IL-1beta mRNA expression after L5 SNT differ. RNA interference may be a method of reducing the development of mechanical allodynia and hyperalgesia in response to nerve injury.

Corrigendum: The time-course and RNA interference of TNF-alpha, IL-6, and IL-1beta expression on neuropathic pain induced by L5 spinal nerve transection in rats (Korean J Anesthesiol 2015 April 68(2): 159-169) / 대한마취과학회지

This article was inadvertently omitted Acknowledgments section for grant support.

Oncologic and Functional Outcomes of Supraglottic Partial Laryngectomy: 18 Years Experience / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Supraglottic partial laryngectomy (SPL), which provides the removal of selected tumors involving the upper structure of the glottis, shows equivalent oncologic outcome when compared to total laryngectomy with functional preservation. We report our 18-year experience of applying supraglottic partial laryngectomy in the Yonsei Head and Neck Cancer Clinic. SUBJECTS AND METHOD: We retrospectively reviewed the charts of 78 patients who underwent SPL. We divided the patients into two groups, the early and the recent, and performed Kaplan-Meier survival analysis and chi2-test on the groups. The post-operative functional outcome was assessed. RESULTS: The 3-year-disease-specific survival rate of the early and recent period was 87% and 84.6%, respectively. Decannulation and tolerability of an oral diet was possible in 93% and 95% of the earlier group, and 95% and 98% in the recent group, respectively. There was no statistically significant difference in survival rate, recurrence pattern, decannulation and tolerability of oral diet between the two groups. CONCLUSION: We achieved a satisfactory survival rate through SPL. In addition, almost all patients could be decannulated and eventually tolerated an oral diet. Our results confirm that SPL is an oncologically & functionally sound procedure for selected supraglottic tumors.

A Case of Liposarcoma Arising in Tracheoesophageal Groove / 대한이비인후과학회지

Liposarcoma is the second most common soft tissue sarcoma in adult, after malignant fibrous histiocytoma. But, the incidence of liposarcoma in the head and neck malignancies is approximately 1.8-6.3%. Primary liposarcoma of the thyroid gland is exceedingly rare with only six previous reports in the English literature. We report a case of liposarcoma in a 61-year-old male who had been misdiagnosed with thyroid nodule and follicular neoplasm suspected in fine needle aspiration cytology. Mass excision of the liposarcoma was performed. During the preoperative evaluation and operation, the author recognized that the tumor had origina-ted not from the thyroid gland, but from the tracheoesophageal groove. The histopathological examination revealed a combination type liposarcoma that was both well differentiated and myxoid. But a paramedian fixation was found in the left vocal cord palsy and injection la-ryngoplasty was performed. Postoperatively, radiotherapy was given to the neck region. Dur-ing the 36-month follow-up period, there was no evidence of the disease.

MRI Findings of a Cholesteatomatous Labyrinthine Fistula Showing Abnormal Inner Ear Enhancement / 대한평형의학회지

A 59-year-old male patient presented with sudden onset of vertigo and hearing loss. Labyrinthitis due to lateral semicircular canal fistula caused by cholesteamatous otitis media was suspected from temporal bone computed tomography (CT) and clinical symptoms. The patient was treated with canal wall down mastoidectomy with removal of the cholesteatoma and lateral semicircular canal occlusion. Preoperative gadolinium-enhanced magnetic resonance imaging (MRI) images of the inner ear revealed increased signal in the cochlea as well as vestibule. Correlation of the MRI findings and the inner ear involvement in labyrinthine fistula is discussed.

The optimal concentration of siRNA for gene silencing in primary cultured astrocytes and microglial cells of rats / 대한마취과학회지

BACKGROUND: Small interfering RNAs (siRNAs) have been used to knockdown specific gene expression in various cells. Astrocytes and microglial cells play a key role in fundamental central nervous system functions and in chronic neuroinflammation. The aims of this study were to determine the optimal concentration of siRNA demonstrating efficient transfection and inhibition of gene expression via RNA interference (RNAi) and lower cytotoxicity, in primary cultured astrocytes and microglial cells of rats. METHODS: Astrocytes and microglial cells were isolated from the cerebral cortices of 2-day-old rats. Both the cells were transfected using transfection reagent (Lipofectaminetrade mark 2000), and fluorescein-labeled double-stranded RNA (dsRNA) or siRNA targeting green fluorescent protein. Transfection efficiency and cytotoxicity of dsRNA, and the degrees of RNAi induced by siRNA in these cells, were evaluated at various concentrations of RNA. RESULTS: Transfection efficiencies of dsRNA in both astrocytes and microglial cells were significantly higher (P < 0.05) at the concentrations of 20, 40, and 80 nM than at the concentrations of 0, 5, and 10 nM. There were no significant cytotoxicities within the applied concentrations of dsRNA (0-80 nM). The degrees of RNAi induced by siRNA were significantly higher (P < 0.05) at the concentrations of 5, 10, 20, 40, 80 nM, and 20, 40, 80 nM in astrocytes and microglial cells, respectively, compared with the control (0 nM). CONCLUSIONS: The siRNA concentration of 20 nM may be appropriate to induce RNAi in both astrocytes and microglial cells, while demonstrating low cytotoxicity, high transfection efficiency, and effective RNAi.