Etiology and Related Factors of Postoperative Delirium in Orthopedic Surgery

BACKGROUND: Delirium is a serious complication for elderly patients after orthopedic surgery. The purpose of this study was to assess the etiology and related factors of delirium after orthopedic surgery in Korea. METHODS: We retrospectively reviewed the medical records of 3,611 patients over 50 years who had orthopedic surgery. The age of patients (50s, 60s, 70s, and > 80s), type of anesthesia (general, spinal, and local), operation time (more than 2 hours vs. less than 2 hours), surgical site (spine, hip, knee, or others), and etiology (trauma or disease) were compared to determine possible risk factors of delirium after orthopedic surgery. RESULTS: Of 3,611 patients, 172 (4.76%) were diagnosed with delirium after orthopedic surgery. Postoperative delirium occurred in 1.18% in their 50s, 3.86% in their 60s, 8.49% in their 70s, and 13.04% in > 80s (p < 0.001). According to anesthesia type, 6.50% of postoperative delirium occurred after general anesthesia, 0.77% after spinal anesthesia, and 0.47% after local anesthesia (p < 0.001). More than 2 hours of operation was associated with higher occurrence of delirium than less than 2 hours was (5.88% vs. 4.13%, p = 0.017). For the etiology, 8.17% were trauma cases and 3.02% were disease (p < 0.001). Postoperative delirium occurred in 22 of 493 patients (4.46%) after spine surgery, 18 of 355 patients (5.07%) after hip surgery, 17 of 394 patients (4.31%) after knee surgery, and 15 of 1,145 patients (1.31%) after surgery at other sites (p < 0.001). CONCLUSIONS: Postoperative delirium was more common in older patients who had surgery under general anesthesia, whose surgery took more than 2 hours, and who were hospitalized through the emergency room.

Nasal Rhinoscleroma in a Nonendemic Area: A Case Report

Rhinoscleroma is a chronic, granulomatous infectious lesion most frequently affecting the respiratory tract mucosa. This disease is endemic to Africa, Central and South America, South Central and Eastern Europe, the Middle East, and China. We report an extremely rare disease of nasal rhinoscleroma in Korea. The patient was a 63-yr-old man, who suffered from chronic nasal obstruction and septal deviation. Characteristic histology from a nasal biopsy was proven and special stains for bacteria were employed: periodic acid-Schiff, Warthin-Starry silver, Giemsa, and Gram stains. Isolation of Klebsiella rhinoscleromatis from a culture of nasal discharge was failed, but ultrastructural examination of numerous phagocyzed bacilli in the Mikulicz cells confirmed the diagnosis. The histiocytic nature of the Mikulicz cells was confirmed, using CD 68 and alpha-1 antitrypsin, and by the ultrastructural features of Mikulicz cells. Here, we emphasize the recognition of this rare entity in nonendemic regions, frequently leading to delayed diagnosis.

Effects of Low-Dose Long-Term Macrolide Therapy on the Postoperative Symptom Change, Mucociliary Clearance and Polyp Regrowth

Low-dose long-term macrolide therapy (LDLMT) has been reported as an effective treatment in chronic respiratory tract diseases such as diffuse panbronchiolitis and chronic paranasal sinusitis. The mechanism of action of LDLMT is not fully revealed. The aim of this study was to evaluate the clinical effect of LDLMT on the postoperative patients of chronic sinusitis with polyp. Thirty eight control groups were defined empirically treated with antibiotics after endoscopic sinus surgery (ESS) and 62 experimental group were defined 8 weeks LDLMT (Clarithromycin 250 mg ) after postoperative 2 weeks in ESS patients. Preoperatively, we checked mucociliary clearance with saccharine test (MCT), symptom scores and sinus CT scan and total IgE, and allerg ic skin test were evaluated for allergy. After ESS, MCT and symptom scores were checked on postoperative patients at 2, 6 and 10 weeks, respectively. Recurrence of polyp was also evaluated with endoscopic examination. The improvement rate (IR) of MCT was s ignificantly higher in the experimental group than in the control group, but the IR of symptom scores was not significant statistically. High total IgE affected the IR of MCT and symptom scores in the experimental group. Allergy proven by allergic skin test also affected the IR of MCT, but the IR of symptom scores was not affected in the experimental group. The polyp recurrence rate was significantly higher in the control group compared to the experimental group. We can conclude that LDLMT has a beneficial affect on the postoperative treatment of sinusitis patients and high total IgE and allergy may affect the effect of LDLMT in postoperative patients who have undergone ESS.

Clinical and Histologic Features of Antrochoanal Polyps

Antrochoanal polyp (ACP) usually appears as a large, soft, gelatinous mass in the nasopharynx. Recently, ACP is considered as a separate entity among sinonasal polyps. Histologically, the antral part of the polyp can be cystic or polypoid with a fibrous and solid choanal part. However, the extent of inflammation of the paranasal sinuses has not well been demonstrated. In addition, pathologic patterns of ACP have not been well revealed. The aim of our study is to evaluate the disease patterns of ACPs by clinical and pathologic analysis. Thirty two patients with ACPs were evaluated by a retrospective study. We evaluated sinus involvement by operative findings and pathologic patterns were investigated in 28 cases by predominant infiltrating cells and types of polyp. In order to evaluate the histologic differences between the antral and choanal portion, each A CP was divided into proximal and distal portion. The involved sinuses were multiple and diverse and the most of them had a polyp. The most common pathologic type was chronic inflammatory polyp. Lymphocyte and neutrophil were visualized in many ACPs predominantly. The histologic differences between the proximal and distal portion was not observed significantly. Clinical analysis suggest that ACPs are not sole polyp but mixed disease with inflammation of the nose and sinuses in most cases. Histologic analysis suggest that ACPs are caused by chronic inflammation in many cases and each portion of ACPs is composed of the same histologic type.

Clinical Values of Fine Needle Aspiration Biopsy in Salivary Gland Diseases / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Diversity of opinion regarding the impact of fine needle aspiration biopsy (FNAB) on clinical decision-making has persisted, mostly because of its high false-negative rate and lower sensitivity in salivary gland diseases when compared to other head and neck tumors. The objectives of this study are to evaluate the utility of FNAB in the diagnosis of salivary gland pathologies and to assess its capacity to provide an accurate medical and surgical treatment. MATERIALS AND METHODS: From June 1989 through January 2000, FNABs were carried out on 50 patients with salivary gland diseases. Among them, 34 patients were confirmed histologically after surgery and others clinically. RESULTS: Regarding the capacity of FNAB to discriminate between neoplastic (malignant and benign) and non-neoplastic lesions, FNAB correctly diagnosed 87% (41/47) of lesions. The values for sensitivity, specificity and accuracy of differentiation for neoplastic lesions were 17%, 95% and 87%, respectively. FNAB's diagnostic accuracy, sensitivity and specificity to Warthin's tumor was higher than to those of pleomorphic adenoma. CONCLUSION: Fine needle aspiration biopsy of salivary gland diseases is a helpful adjunctive test for diagnosis and treatment planning.

House Dust Mite Allergic Rhinitis Model in C57BL/6 Mice / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The animal model of allergic rhinitis is important to study the pathophysiology of allergy and to design an effective therapy to ameliorate allergic diseases. Despite of numerous reported animal models of allergic rhinitis, there were few reports of murine model sensitized with house dust mite, which is one of the most common antigen that induce allergic rhinitis. The aim of this study was the establishment of the murine model for house dust mite allergy. MATERIALS AND METHODS: C57BL/6 mice were sensitized with Dermatophagoides farinae (Der f) crude extract in complete Freund's adjuvant and repetitive intranasal instillation of Der f extract a total of 6 times at 1 week intervals (group A). In some mice, allergen was intranasally instilled at 1 week intervals without sensitization of allergen (group B). RESULTS: After allergen challenge, nasal symptoms were significantly increased in group A mice. Histopathologically, the number of eosinophil in nasal mucosa were also significantly increased in group A and B mice. High level of Der f-specific IgE antibody was observed in group A mice, whereas those of group B mice was low. CONCLUSION: Our findings suggested that house dust mite allergy can be developed by systemic sensitization of Der f extract with adjuvant and intranasal instillation of allergen. This is more effective method than local sensitization of allergen only.

Expression and Role of Adhesion Molecules in the Nasal Mucosa of the Rat with Experimentally Induced Allergic Rhinitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Airway allergic reactions are induced by infiltrating inflammatory cells into the human airway tissues through interactions between vascular endothelial cells, inflammatory mediators and adhesion molecules. Accordingly, it is important to study the role of adhesion molecules for the evaluation of pathophysiology of allergy. The aim of this study is to investigate the effect of monoclonal antibodies against intercellular adhesion molecule-1 (ICAM-1) and leukocyte function associated molecule-1 (LFA-1) on the pathophysiology of allergy in ovalbumin-sensitized rats. MATERIALS AND METHODS: We developed an allergy model in rat using the intraperitoneal injection and intranasal nebulization of ovalbumine solution. We evaluated in vivo effects of ICAM-1 and LFA-1 monoclonal antibodies on the expression of ICAM-1 and LFA-1 in ovalbumin sensitized rats. RESULTS: Nasal symptoms after allergen challenge were significantly suppressed and the number of eosinophil in nasal mucosa were significantly inhibited by the treatment of adhesion molecule antibodies. Anti-ICAM-1 and anti-LFA-1 monoclonal antibodies suppressed the expression of ICAM-1 and LFA-1 in nasal mucosa of ovalbumin-sensitized rats. CONCLUSION: It is suggested that allergy can be managed by a useful treatment method using adhesion molecule antibody.

Culture of Tonsillar Follicular Dendritic Cells / 대한면역학회지

Presentation of antigen in a suitable form to lymphocytes is prerequsite for the initiation of primary immune response. Dendritic cells (DC) provide an effective pathway for presenting antigens to lymphocytes in situ. The aim of this study was to establish a dendritic cell-line from human tonsils and to investigate the changes in surface phenotype during culture. Immunohistochemical studies using various surface markers indicated that cultured DC were follicular dendritic cells (FDC) from human tonsils. Cultured DC showed typical dendritic morphology at early stage of culture. Their shape changed into fibroblast-like cells over culture time. Surface phenotype study suggested that cultured DC were distinct from human fibroblast. Antigenic pattern of FDC was changed during culture; I-ILA-DR antigens decreased and HJ2 antigens increased with aging of culture. Functional characteristics of human tosillar FDC will be investigated in the future.

Effects of beta-toxin of Staphylococcus aureus and Neuraminidase of Streptococcus pneumoniae on Ciliary Activity of Nasal Ciliated Epithelial Cells

BACKGROUND AND OBJECTIVES: The in vitro effects of pneumococcal neuraminidase and staphylococcal beta-toxin on ciliary activity were investigated at different concentrations and lengths of exposure. MATERIALS AND METHODS: The ciliated epithelial cells were taken from the maxillary sinus mucosa of rabbits. Ciliary beat frequency (CBF) was measured at concentrations of 0.01, 0.1 and 1.0 U/mL of neuraminidase and 0.1, 1.0, 2.0, 5.0 and 10 U/mL of beta-toxin using a video-computerized analysis technique. The CBF was measured 2, 4, 6, 12, 24 and 48 hours after administration of the neuraminidase and beta-toxin. In the control group, normal saline was percutaneously applied to the right maxillary sinus. In the experimental group, 2 U/mL of beta- toxin was applied to the left maxillary sinus using the same technique. At 7 days, all of the mucosae were taken from the inferomedial wall of the maxillary sinus for light microscopy. RESULTS: There was no change in CBF during a 48-hour incubation at 0.01, 0.1 and 1.0 U/mL of neuraminidase. However, the CBF dropped significantly after an 8-hour incubation at 2.0 U/mL of beta-toxin (p<0.05, repeated measures ANOVA). No ciliary activity was observed after a 12-hour incubation at 10 U/mL of beta-toxin. The mucoid, purulent discharge was observed in the maxillary sinuses of the experimental group. Prominent epithelial disruption and infiltration of inflammatory cells into the epithelium and lamina propria were observed in the beta-toxin-applied group. CONCLUSION: The results of this study suggest that staphylococcal beta-toxin may reduce ciliary activity and induce sinusitis without occlusion of the natural ostium of the maxillary sinus in rabbits. This study provides another animal model of sinusitis for understanding the pathogenesis of sinusitis caused by bacterial exotoxins.

Quantitative Evaluation of Efficacy of Systemic Steroid Therapy for the Patients with Olfactory Disturbance / 대한이비인후과학회지

OBJECTIVES: This study quantifies the efficacy of a short-term systemic steroid therapy in the patients with anosmia or hyposmia using the butanol threshold test (BTT) and the visual analogue scale (VAS). MATERIALS AND METHOD: Thirty patients with anosmia or hyposmia were included in this study from June 1996 through April 1997. The patients were divided into inflammatory and noninflammatory groups depending on the etiology. We evaluated the patients before and after the systemic steroid admi-nistration using both BTT and VAS. RESULTS: Overall improvements of olfactory function was observed upto 70% by BTT and 53% by VAS, and the therapeutic effect of steroid on olfactory malfunction was statistically significant (p=0.0001). Improvements in the olfaction was measured by BTT, which correlated strongly with the measurements by VAS with statistical significance (r=0.77578, p=0.0001). The inflammatory group showed better steroid response (83%) than the noninflammatory group (61%), but there was no statistical significance. CONCLUSION: The systemic steroid administration may be effective in the treatment of olfactory disturbance with a good correlation between BTT and VAS.

A Comparison of the Therapeutic Effects of Powder and Aerosolized Budesonide in the Treatment of Perennial Allergic Rhinitis

The aims of this study are to compare the efficacy and side effects of intranasal budesonide as a dry powder and as a freonpropelled pressurized aerosol in the treatment of perennial allergic rhinitis and to assess the difference in compliance with the powder and aerosol. The study design was a randomized, double-blind crossover between two treatment groups over a six-week period. Twelve patients with symptomatic perennial allergic rhinitis received 400 microgram of intranasal budesonide administered daily as two puffs/nostril/day of the drug delivered by a freon-propelled aerosol for the first three weeks and as one inhalation/nostril/day of the pure drug powder for the next three weeks. Fourteen adults with allergic rhinitis received the drug in the reverse sequence. Patients recorded daily symptoms on diaries, and, at each clinic visit, adverse effects were recorded. Compliance with the powder and with the aerosol was also evaluated. During the six weeks, there were significant improvements in symptoms in both treatment groups, and the differences in efficacy and compliance with the medication between the two groups were not significant. Adverse effects included headaches, epistaxis, and nasal dryness ; however, they were not serious and equally distributed in the two groups. We conclude that powder and aerosolized budesonide improve the symptoms of perennial allergic rhinitis significantly with little difference in efficacy, side effects, and preference.

A Comparison of the Therapeutic Effects of Powder and Aerosolized Budesonide in the Treatment of Perennial Allergic Rhinitis

The aims of this study are to compare the efficacy and side effects of intranasal budesonide as a dry powder and as a freonpropelled pressurized aerosol in the treatment of perennial allergic rhinitis and to assess the difference in compliance with the powder and aerosol. The study design was a randomized, double-blind crossover between two treatment groups over a six-week period. Twelve patients with symptomatic perennial allergic rhinitis received 400 microgram of intranasal budesonide administered daily as two puffs/nostril/day of the drug delivered by a freon-propelled aerosol for the first three weeks and as one inhalation/nostril/day of the pure drug powder for the next three weeks. Fourteen adults with allergic rhinitis received the drug in the reverse sequence. Patients recorded daily symptoms on diaries, and, at each clinic visit, adverse effects were recorded. Compliance with the powder and with the aerosol was also evaluated. During the six weeks, there were significant improvements in symptoms in both treatment groups, and the differences in efficacy and compliance with the medication between the two groups were not significant. Adverse effects included headaches, epistaxis, and nasal dryness ; however, they were not serious and equally distributed in the two groups. We conclude that powder and aerosolized budesonide improve the symptoms of perennial allergic rhinitis significantly with little difference in efficacy, side effects, and preference.

Cochlear Fistula: Report of 2 Cases / 대한이비인후과학회지

Labyrinthine fistula is not infrequent findings in cholesteatoma surgery. Fistula most commonly involve the horizontal semicircular canal, but a fistula into the cochlea is rare. The authors describe two cases of cochlear fistulas in chronic otitis media with cholesteatoma.