Role and Effectiveness of Postoperative Voice Therapy in Laryngeal Microsurgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Voice therapy is performed following laryngeal microsurgery to help the recovery of the operation site and assist in optimal voice output. The aim of this study was to evaluate the effect of postoperative voice therapy and to obtain objective evidence about the necessity of voice therapy. SUBJECTS AND METHOD: The voice of 109 patients who underwent laryngeal microsurgery for vocal fold lesions and received voice therapy was analyzed. Voice analysis was performed preoperatively, postoperatively, and after the first voice therapy. GRBAS scale was used for auditory perceptual evaluation and acoustic analysis was performed for objective evaluation. RESULTS: Overall, significant improvement was observed postoperatively in both auditory perceptual evaluation and acoustic parameters, and significantly better voice was obtained after the first postoperative voice therapy. The degree of postoperative voice improvement varied on the type of vocal fold lesions, but voice quality was improved in all diseases after first postoperative voice therapy. The number of voice therapy decreased significantly as the voice quality improved after the operation or the first voice therapy. Four or more voice therapy were needed when the cepstral/spectral index of dysphonia (CSID) value was 5.88 or higher. CONCLUSION: Voice therapy following laryngeal microsurgery was effective in better voice output. The CSID value after the first postoperative voice therapy was predictive of finding patients who need long-term voice therapy. These results suggest that the first postoperative voice therapy will be helpful in finding the adequate vocalization method and providing objective evidence for selecting patients who would require continuous voice therapy.

Effect of Topical Propolis on Wound Healing Process After Tonsillectomy: Randomized Controlled Study

OBJECTIVES: The post-tonsillectomy pain and post-tonsillectomy hemorrhage are the two main problems after tonsillectomy. The aim of this study was to investigate the beneficial effects of water soluble ethanol extract propolis on post-tonsillectomy patient. METHODS: One hundred and thirty patients who underwent tonsillectomy or adenotonsillectomy were randomly divided into the control and propolis groups, each including 65 patients. The propolis group was applied with propolis orally immediately after surgery and by gargle. The pain scores were assessed on post-tonsillectomy 0, 1st, 2nd, 3rd, and 7th–10th day using a visual analogue scale score. Postoperative wound healing was evaluated by scoring pinkish membrane of tonsillar fossae on postoperative days 3 and 7–10. The incidence of post-tonsillectomy bleeding was examined in each group. RESULTS: Post-tonsillectomy pain was significantly less in propolis group compared to control group on postoperative days 3 and 7–10. Post-tonsillectomy hemorrhage was significantly less in the propolis group compared to the control group (P < 0.05). The wound healing was significantly better in the propolis group compared to the control group on postoperative day 7–10 (P=0.002). CONCLUSION: Applying the propolis to post-tonsillectomy wound showed beneficial effect of reducing postoperative pain, preventing hemorrhage, and accelerating of wound healing of tonsillar fossae.

A Case of Venous Malformation of the Pyriform Sinus Treated with Ethanol Sclerotherapy

We describe a case of venous malformation of pyriform sinus in 63 year-old patient, discovered incidentally. Venous malformation are the most common vascular malformations to arise in the head and neck. However venous malformation of the hypopharynx in the adult papulation are rare. The author performed successfully ethanol sclerotherapy for venous malformation of pyriform sinus, so we present the case with a review of the related literatures.

A Case of Mediastinal Ectopic Thyroid Cyst Inducing Severe Airway Compression / 대한이비인후과학회지

Ectopic thyroid gland is usually located along the development path of thyroid in the anterior midline of the neck. However, its occurrence within the mediastinum is very rare. Mediastinal ectopic thyroid cyst is usually benign and asymptomatic, but we experienced a case of the mediastinal ectopic thyroid cyst inducing a severe airway obstruction in a 45-year-old male. The mass had no connection to the cervical thyroid gland and histological examination revealed a mediastinal cyst of an ectopic thyroid. We present the case with a review of the related literatures.

A Case of Aryepiglottoplasty under Conventional Ventilation in Congenital Laryngomalacia Patient / 대한이비인후과학회지

Laryngomalacia is reported as the most common cause of congenital laryngeal stridor. Despite its benign and self-limited aspects, 10% of all cases require intervention. However, endolaryngeal surgery in neonates makes great demands on the anesthesiologist and the surgeon because of the narrowness of the airways. This case report will present a surgical management of severe laryngomalacia in a newborn using the combination carbon dioxide laser and cold instrument to surgically divide the aryepiglottic fold under conventional ventilation.

Analysis of Acoustic Parameters to Objectively Reflect the Change of Voice Quality before and after Surgery in Benign Vocal Fold Mucosal Disorders / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to compare between preoperative and postoperative voices by subjective auditory perceptual evaluation and objective acoustic analysis. The study also analyzed the acoustic parameters that best reflected the auditory perceptual characteristics in laryngeal microsurgery. SUBJECTS AND METHOD: The records of 49 patients who had been diagnosed as benign vocal fold mucosal diseases and had undergone laryngeal microsurgery were retrospectively analyzed. Preoperative and postoperative voices were assessed by auditory perceptual evaluation using the GRBAS Scale and acoustic analysis using Multi-Dimensional Voice Program (MDVP) and Analysis of Dysphonia in Speech and Voice (ADSV). Correlation between auditory perceptual characteristics and acoustic parameters was analyzed. RESULTS: Auditory perceptual evaluation showed that the patients' voices were improved after the operation. Several acoustic parameters of MDVP related to short-term and long-term variability showed significant improvement. Also, there were significant differences in several cepstral/spectral parameters of ADSV after operation. In the correlation analysis, the overall grade (G) of the GRBAS Scale showed highest correlation with the cepstral spectral index of dysphonia (CSID) (r=-0.700). The roughness (R) of GRBAS Scale was correlated with the smoothed amplitude perturbation quotient of long-term variability of MDVP (r=0.468), breathiness (B) with cepstral peak prominence (r=-0.703) and strain (S) with CSID (r=0.650) (p<0.01). CONCLUSION: Our results showed that the acoustic parameters were related to the long-term variability of MDVP, and the parameters of cepstrum/spectrum were useful for the objective assessment of voice quality in patients who received laryngeal microsurgery. These parameters were also useful for the quantification of voice quality and abnormality of phonation.

Metastatic Lymph Node Ratio of Central Neck Compartment Has Predictive Values for Locoregional Recurrence in Papillary Thyroid Microcarcinoma

OBJECTIVES: This study aimed to evaluate the significance of metastatic lymph node ratio (the ratio between the metastatic lymph node and the harvested lymph nodes; MLNR) in the central neck for the prediction of locoregional recurrence in patients with papillary thyroid microcarcinoma. METHODS: After reviewing medical records of papillary thyroid microcarcinoma patients who received total thyroidectomy with central neck node dissection, 573 consecutive adult patients were enrolled in this study, with a follow-up period of more than 36 months. Regarding the risk of recurrence, multivariate analyses were performed with the following variables; sex, age, multiplicity of the primary tumor, presence of pathological extrathyroidal extension, the level of postoperative stimulated serum thyroglobulin, the number of harvested lymph nodes, the number of lymph node metastasis and MLNR. RESULTS: The MLNR showed a predictive significance for the locoregional recurrence (P<0.05). Most recurrences were occurred in the lateral neck (n=12, 80%) with a median interval of 20 months. The lowest cutoff value of the MLNR for a meaningful separation of disease recurrence was 0.44 (hazard ratio, 8.86; 95% confidence interval, 1.49 to 52.58; P=0.001). CONCLUSION: When the MLNR is higher than 0.44, there is an increased risk of locoregional recurrence mostly in the lateral neck. Therefore, MLNR of the central neck in a permanent or frozen biopsy may be helpful in decision making in the extent of thyroidectomy and/or the need for contralateral central neck lymph nodes dissection.

A Case of Successful Use of C-MAC® Video Laryngoscope in ‘Cannot Ventilate’ Situation Due to Unexpected Severe Narrowing of Laryngeal Inlet

Although many factors associated with difficult intubation have been known, predictors of difficult mask ventilation are not well known. We experienced a case of nearly complete airway obstruction following usual anesthetic induction which needed various emergency treatments. The patient had a preoperative diagnosis of contact granuloma of right posterior vocal cord and bilateral vocal cord palsy but later was found out as invasive laryngeal cancer. Upon the surgical field of view, both vocal cords were showing significantly thickened and fixated appearance and was considered as in the critical narrowing state with the potential of complete obstruction. Using C-MAC® video laryngoscope we were able to see the narrowed vocal cord and choose proper size of endo-tracheal tube. Consequently, intubation was successfully done and operation was conducted. From this case, we have lessons that physicians should examine the patient's airway more carefully in case of laryngeal mass and prepare emergency measures.

Usefulness of the Modified LRINEC Score in the Treatment of Patient with Deep Neck Infection / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Deep neck infection can occur at any age and is a potentially life-threatening diseases. However, an early recognition of aggravating infections is clinically difficult. In this study, we aimed to determine the Modified Laboratory Risk Indicator for Necrotizing Fasciitis (M-LRINEC) scores to predict aggravating deep neck infections. SUBJECTS AND METHOD: We retrospectively analyzed 72 patients with deep neck infection from January 2010 and December 2012 in a tertiary hospital. Differences in patient characteristics, radiographic findings, LRINEC scores, and M-LRINE scores were compared between the non-surgical group and the surgical group. RESULTS: The mean M-LRINEC scores were 4.35 and 1.39 in the surgical group and non-surgical group, respectively. Significant differences between the two groups were found in age, size of abscess, multiple spaces involvement, air collection, and mediastinitis. CONCLUSION: The M-LRINEC score is an useful indicator that signals the need to initiate early surgery and also to predict aggravating deep neck infections.

A Case of Treating Anterior Glottic Web by Laser Mucosal Inversion Technique / 대한이비인후과학회지

Anterior glottic web is an abnormal scar tissue formation between the vocal folds, involving anterior commissure. Scarring procedure caused by damage to mucosal membranes of the vocal folds eventually can lead to glottic web formation, especially after laryngeal surgery involving both vocal folds. The conventional treatments of anterior glottic web have included keel, silicon or tube insertion. However, this presents risks of airway compromise and granulation tissue formation. CO2 laser web lysis has been widely used over the past decades. We introduced a novel, laser mucosal inversion technique for treating anterior glottic web and presented the case with a review of the related literatures.

Early Neck Exercises to Reduce Post-Thyroidectomy Syndrome after Uncomplicated Thyroid Surgery: A Prospective Randomized Study / 대한갑상선학회지

BACKGROUND AND OBJECTIVES: To evaluate the efficacy and safety of early neck exercises to reduce post-thyroidectomy symptoms and syndromes for patients undergoing thyroid surgery. MATERIALS AND METHODS: One hundred patients who had undergone thyroid surgery were randomly assigned 1:1 to control (delayed exercise, initiating at postoperative 2 weeks) or early exercise group (initiating at postoperative 1 day). Questionnaire survey (voice, globus sense, neck discomfort, swallowing difficulty) and objective measurement (surgical wound adhesion, range of neck motion and scar scale) were performed at 2 weeks and 3 months postoperatively. RESULTS: Compared to control, early exercise significantly decreased the degree of neck discomfort at 2 weeks after thyroid surgery (p=0.037) while other subjective symptoms including voice change, globus sense, and swallowing difficulty were not significantly different between the two groups. The degree of surgical wound adhesion was significantly decreased (p<0.001) and the range of motion was improved in early exercise group (p=0.010). In addition, the objective scores of Vancouver Scar Scale (VSS) were decreased in early exercise group compared to those of control group (p=0.020). CONCLUSION: Early neck exercises are safe and effective to reduce postoperative neck discomfort, wound adhesion, or hypertrophy of scar and to improve the range of motion in patients undergoing thyroid surgery.

A Case of Ectopic Hamartomatous Thymoma / 대한이비인후과학회지

Ectopic hamartomatous thymoma (EHT) is a rare and distinctive benign tumor that usually occurs in the supraclavicular, suprasternal areas. Histopathologically, it is characterized by a mixture of spindle cells, epithelial cells, and adipose cell elements. The recognition of EHT and differentiation of it from high-grade sarcomas such as synovial sarcoma is important, because EHT follows a benign clinical course and conservative surgical excision is the treatment of choice. We experienced a case of EHT in the supraclavicular area, so we present the case with a review of the related literatures.

A Clinical Analysis of Peritonsillar Abscess / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Peritonsillar abscess (PTA) is the most common deep neck infection that occurs in adults, but until now there are so many controversies about the treatment modalities. The purpose of this study is to investigate the clinical course according to the treatment modalities for peritonsillar abscess and to evaluate the efficacy of tonsillectomy. SUBJECTS AND METHOD: Two hundred twenty-six patients with peritonsillar abscess admitted from January 1999 to October 2006. Among them, a retrospective review of medical records and additional telephone interview were performed on 151 cases. RESULTS: Among 151 cases, incision and drainage (I&D) was performed in 132 cases: 7 cases were done by aspiration and others were treated by antibiotics only. There was no significant difference in the dutarion of hospitalization between I&D, aspiration and antibiotics only (p>0.05). The incidence of recurrent PTA was only 6.6% (10/151). Tonsillectomy in PTA patients significantly reduced duration, frequency and severity of sore throat in long term follow up (p<0.05). CONCLUSION: The duration of hospitalization in PTA patients did not depend on treatment modalities. We conclude that tonsillectomy is not always necessary due to low incidence of recurrent PTA even though it improves satisfaction of PTA patients.

The Effect of IP3 Receptor Inhibition Using 2-APB on Gentamicin Ototoxicity in Cochlear Sensory Cell / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Elevated intracellular calcium level is known to play important roles in the apoptotic pathway. IP3 receptor (ligand-gated channels that release Ca2+ from intracellular stores) is emerging as a key site for regulation of apoptosis. 2-Aminoethoxydiphenyl borate (2-APB) is one of the reliable IP3 receptor antagonists. We examined the effect of 2-APB on gentamicin ototoxicity in vitro, using the HEI-OC1 cell line. MATERIALS AND METHOD: HEI-OC1 cells were trWWeated with 100micrometer gentamicin. Using a CaspACE assay, we measured the caspases-3 activity in the gentamicin treated hair cells with and without 2-APB pre-incubation. We also observed intra-cellular calcium concentrations in HEI-OC1 cells using a confocal microscopy (calcium green-1 stain). Live cell imaging was performed by using fluorescence video-time lapse system. RESULTS: Cytosolic calcium elevation by gentamicin was remarkably inhibited by 2-APB. Caspases-3 activities of gentamicin treated cells were higher than those of the control. After incubation with 2-APB, caspases-3 activities and cell death of gentamicin treated cells were shown to decrease. CONCLUSION: 2-APB reduces Caspases-3 activity in the gentamicin treated HEI-OC1 cells by inhibition of cytosolic calcium increase.

Photodynamic Therapy(PDT) for Early Glottic Cancer which was Recurred after Initial Treatment Modality / 대한이비인후과학회지

Photodynamic therapy (PDT) is a method used to treat cancer early by irradiating laser with suitable wavelength after injection of a photosensitizer. We introduce the result of PDT for treating an early glottic cancer where initial treatment modality had failed. We tried PDT for 2 patients: one had recurrence after laser cordectomy (T1b) and the other after radiation therapy (T2). Photogem 2 mg/kg was injected intravenously and laser irradiation was performed after 48 hours. We irradiated the lesion site using diode laser (630 nm) delivered through 5 mm cylindrical fiber tip. The energy density, as determined by the depth and site of the lesion, were 138 J/cm and 204 J/cm, respectively. Patient with T1b is alive with no evidence of disease for 46 months post-PDT follow up. Patient with T2 developed chondritis at the subglottis but improved after hyperbaric oxygen therapy and several surgical debridement. After 4 months, tumor recurred at both vocal folds and was managed with total laryngectomy. PDT is a new treatment modality with advantages of good voice quality, short period of admission, and less rate of morbidity and may be another useful salvage option.

Clinical and Radiologic Characteristics of Kikuchi's Disease / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Kikuchi's disease (histiocytic necrotizing lymphadenitis) is a rare self-limiting disorder that typically affects the cervical lymph nodes. It has been occasionally misdiagnosed as tuberculous lymphadenitis or malignant lymphoma. In this study, we analyzed the clinical and radiologic characteristics and tried to find the differential points of Kikuchi's disease. SUBJECTS AND METHOD: Fifty-two patients who underwent, from January 1998 to December 2004, a excisional biopsy or fine needle aspiration of a cervical lymph node and diagnosed histologically with Kikuchi's disease were enrolled in this study. We retrospectively reviewed the medical record and imaging of each patient. The patients were followed up for a period of 14 to 200 seven days. RESULTS: Patients were 36 women and 16 men (2.3:1) with the mean age of 23.7 years old. The affected cervical lymph nodes were most commonly located in the posterior cervical triangle (Level V, 83%). Multiple and unilateral cervical lymph nodes were affected in 23 and 16 patients, respectively. The dimensions of affected lymph nodes were in the range of 1 to 2.5 cm (mean 1.73 cm). Leukopenia was observed in 21 patients (46%) fever in 24 patients (46%). CT finding of Kikuchi's disease appeared to be similar to tuberculous lymphadenitis but it had more homogenous density. One patient was recurred after 104 days since she was diagnosed as Kikuch's disease by biopsy. CONCLUSION: The difinite diagnosis of Kikuch's disease was determined by pathology. But half of the patients show clinical and radiologic features suggestive of Kikuch's disease. Short term use of steroid with high index of suspicion will reduce the unnecessary open biopsy in patient with Kikuchi's disease.

Expression of TGF-beta Induced Protein, betaig-h3, in Chronic Wound and It's Effect on Wound Healing

betaig-h3 is highly induced in A549 cells(human lung adenocarcinoma) after growth arrest by transforming growth factor-beta1. Although some reports describe variable functions of betaig-h3, it's function is in part controversial. betaig-h3 is a TGF-beta inducible cell adhesion molecule and some authors contend that recombinant betaig-h3 supports attachment and spreading of dermal fibroblast. Thus, it is expected that betaig-h3 plays a good role in wound healing. In order to investigate the effect of betaig-h3 in wound healing, The expression of TGF-beta and betaig-h3 in normal skin tissues and chronic wounds were examined by immunohistochemistry stain. In addition, 5 types of recombinant betaig-h3 were made, and among them, betaig-h3 b and betaig-h3 e were used for the experiment. Sprague- Dawley white rats served as the experimental models. Four round full-thickness skin defects of 2cm diameter were made on the back of each rat. The experiment was divided into 4 groups according to the content of ointment; group A: Topical application of ointment base only, group B: Topical application of ointment containing fibronectin 100microgram/ml, group C: Topical application of ointment containing betaig-h3 b 100 microgram/ml, group D: Topical application of ointment containing betaig-h3 e 100microgram/ml. In immunohistochemical study on normal human skin, the expression of TGF-beta was located in the upper dermal part, stratum basale, stratum spinosum and stratum granulosum in epidermis. The expression of betaig-h3 in normal dermis was similar with that of TGF-beta, but increased staining was observed in only stratum basale of normal epidermis. In chronic wounds, TGF-beta and betaig-h3 were highly expressed beneath the bottom and margin of wound and there were some cells showing positive staining within the nucleus. In animal models applied ointment, the reduction of wound size was more marked in group B, C, D than in group A. More rapid reepithelialization, less fibroplasia, less infiltration of inflammatory cells, more capillary formation in early period and more rapid collagen formation were seen in betaig-h3 treated wounds. In conclusion, betaig-h3 plays an important role in wound healing, and it is expected that recombinant betaig-h3 will become potent material for the treatment of chronic wound.

The Effects of bFGF, VEGF and Micromass Culture on Proliferation and Differentiation of Human Chondrocytes

The acquisition of human chondrocytes for transplantation and cartilage coverage presents a major problem as these cells dedifferentiate rapidly during expansion in monolayer culture. Dedifferentiated chondrocytes change their shapes, metabolic states, and programs of matrix biosynthesis. We initiated this study on the basis of the hypothesis that bFGF, VEGF, and micromass culture can influence both the proliferation and their ability to express COL2A1 gene as a chondrogenic marker and Cbfa1 gene as an osteogenic marker. Chondrocytes in monolayer and micromass culture with or without bFGF and VEGF in vitro were collected and analyzed. In results, bFGF stimulated the proliferation of chondrocytes in monolayer culture. VEGF also stimulated the proliferation, but was less effective. The phenotype of chondrocytes was gradually changed in monolayer culture. Chondrocytes expanded in the presence of bFGF became dedifferentiated. However, dedifferentiated chondrocytes fully maintained their potential for redifferentiation in response to environmental changes. After transferring in micromass culture, chondrocytes which expanded with bFGF demonstrated high COL2A1 expression that was biochemically comparable to primary chondrocytes. Chondrocytes which expanded with VEGF demonstrated high Cbfa1 expression in both monolayer and micromass culture with passage times. This study provides that bFGF is needed to expand chondrocytes during tissue cultivation and additional three-dimensional environment is needed to maintain their differentiated phenotype. VEGF initiates the osteogenic potential during the chondrocyte expansion especially in micromass culture.

Craniofacial Contouring Using Porous Polyethylene(Medpor(R)) Implant

Among the alloplastic implants, porous polyethylene (Medpor(R)) is one of the ideal materials for augmentation of the craniofacial region. The interconnecting open pore structure of Medpor(R) allows for tissue ingrowth which promotes host integration and prevents migration. The firm nature allows easy carving and prevents collapsing. Because of these advantages, Medpor(R) has been well used for reconstruction of orbital wall. From March 1994 to December 2002, 27 patients were performed the craniofacial contouring surgery using Medpor(R). Thirteen patients were male, 14 were female. The causes of operations were as follows: trauma, 16; cosmetic, 8; and others, 3. The sites of implant were as follows: frontal, 8; temporoparietal, 6; zygoma, 5; maxilla, 3; mandible, 3; and periorbital, 2. The follow up period was 6 months to 48 months with an average of 12 months. The implants were placed into the subperiosteal plane, and fixed with titanium screws. After fixation, the final contouring was performed by carving with a knife or shaving with a high speed bur. There was no infection. All implants were in place, and there was no extrusion. All patients were satisfied at the results of the operation. The irregular margin of implant was felt in 3 cases. However, reoperation was not performed in these patients because of minimal irregularity. In conclusion, Medpor(R) allows ingrowth of soft tissue without adverse tissue response, and there is no donor mobidity. Implanted Medpor(R) were not absorbed or distorted. With these advantages, Medpor(R) could be one of ideal implants for craniofacial contouring.

Effect of Growth Hormone on Early Bony Regeneration in Distraction Osteogenesis

The purpose of this project was to study the effect of growth hormone on early bony consolidation in distraction osteogenesis of a dog mandible. Sixteen dogs were used for this study. An external distraction device was applied to the mandibular body and the mandibular distraction was started five days after the operation at a rate of 1 mm per day up to a 10-mm distraction. Dogs in the growth hormone group received a daily subcutaneous injection of 1 IU of recombinant human growth hormone per kilogram of body weight per week. Normal saline was injected in the control group. Bone mineral density was higher in the growth hormone group than the control group in the whole period. Bone mechanical strength was 300% higher in the growth hormone group than that in the control group. However, results were more suggestive than conclusive. Upon histological examination, the formation of a substantial amount of active woven bone was observed throughout the distracted zone in 6 weeks in the growth hormone group. In the control group, new bone was generated from the edge to the center of the distracted zone. But, the most central area of the distracted zone was filled with fibrous tissue in 6 weeks. In conclusion, growth hormone appears to be effective in early bony consolidation in distraction osteogenesis.