The classification, diagnosis, and treatment of rhinosinusitis

Rhinosinusitis, one of the most common conditions encountered by clinicians, affects quality of life and reduces work productivity. Despite its high prevalence and economic burden, there are considerable differences in practice regarding the management of rhinosinusitis. Based on many studies, including the updated guidelines, classifications have been subdivided, and new treatments have been added.Current Concepts: Rhinosinusitis can be classified as acute rhinosinusitis (ARS) or chronic rhinosinusitis (CRS) with a cut-off duration of 12 weeks. It is diagnosed based on subjective symptoms and objective findings on computed tomography or endoscopy. Viral infections account for the majority of the causes of ARS, with watchful waiting without antibiotics as its important initial management. Meanwhile, CRS is divided into primary and secondary CRS, which is further subdivided by anatomic distribution and endotype. Particularly, the Type 2 endotype is characterized by a high recurrence rate and high resistance to current therapies. Biologics using monoclonal antibodies could therefore be used as new therapeutic options for the treatment of primary type 2 CRS. Furthermore, given the chronicity of CRS, it is important to recognize that endoscopic sinus surgery and continuous postoperative medical treatment are important for its management.Discussion and Conclusion: Accurate diagnoses based on diagnostic criteria and subdivided classifications are necessary to determine the treatment plan and prognosis. In particular, it is important to differentiate the endotype of CRS and provide appropriate treatments to improve the patient’s symptoms and quality of life.

Late Metastatic Renal Cell Carcinoma Recurrence Presenting as a Maxillary Sinus Mass 12 Years after Nephrectomy: Case Report and Literature Review

Metastasis to the sinonasal cavity is rare. Late recurrence, such as metastasis developing 10 years or more after nephrectomy, is even more rare. We present a rare case of late metastatic renal cell carcinoma (RCC) in the maxillary sinus after nephrectomy and discuss reported sinonasal metastatic RCC cases. A 64-year-old man presented with left nasal obstruction for the previous one year. He had undergone right nephrectomy to treat RCC 12 years prior. Paranasal sinus computed tomography and magnetic resolution imaging revealed a 4.6-cm-diameter mass exhibiting delayed contrast enhancement that filled the left maxillary sinus and the nasal cavity. Histologically, clear cell RCC was diagnosed. We resected the maxillary sinus tumor to resolve the nasal obstruction for palliative symptom relief. There has been no evidence of recurrence to date, 3 years postoperatively. When a patient with a history of RCC presents with a hypervascular paranasal sinus mass, metastatic RCC should be considered, despite history of nephrectomy. It is important to make an appropriate treatment plan depending on extent of metastases and location of the metastatic tumor.

Endoscopic Trans-Turbinal Medial Maxillectomy: A Modified Endoscopic Medial Maxillectomy Technique to Preserve the Inferior Turbinate / 대한이비인후과학회지

Endoscopic medial maxillectomy (EMM) and its modifications are surgical techniques are used to treat recalcitrant maxillary sinusitis as well as maxillary sinus tumors. In this report, we propose a simple and efficient modification of EMM, called endoscopic trans-turbinal medial maxillectomy (ETTMM), by which the inferior turbinate (IT), nasolacrimal duct, and anatomical integrity of the nasal valve area are preserved. A total of 10 patients (five tumorous and five nontumorous maxillary diseases) underwent ETTMM. Briefly, a turbinate mucosal flap on the superior aspect of the IT was elevated after middle meatal antrostomy. Then a trans-turbinal window was developed to expose the inferior meatus, after which an extended maxillary antrostomy was generated. Finally, the turbinate mucosal flap was repositioned after complete removal of the antral lesions. All lesions were successfully treated using ETTMM. Our modification was easy to perform, and we achieved good endoscopic visualization and accessibility throughout the whole antrum by creating a trans-turbinal window and extended maxillary antrostomy. We could perform postoperative surveillance easily through the wide antrostomy using rigid endoscopes of various angles. ETTMM is a simple and useful modification of EMM that provides clear visualization and great accessibility to most aspects of the maxillary antrum while preserving the nasal functional units, including the IT and nasal valve area.

Posterior Epistaxis: Risk Factors and Causes of Recurrence after Sphenopalatine Artery Ligation / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Most cases of epistaxis can be controlled by conservative management such electrocautery or nasal packing. However, for some cases of the posterior epistaxis, invasive procedures like endoscopic sphenopalatine artery ligation (SPAL) or arterial embolization are needed. In this study, risk factors present in patients who were hospitalized due to posterior epistaxis and postoperative complications and causes of recurrence after SPAL were analyzed. SUBJECTS AND METHOD: A retrospective chart review of 75 patients who were admitted to Gyeongsang National University Hospital for the treatment of posterior epistaxis between 2009 and 2014 was performed. Demographic factors, seasonal variation, comorbid diseases, and laboratory results were analyzed. Furthermore, 35 patients who have undergone SPAL were surveyed by telephone regarding postoperative complications, and preoperative computerized tomography (CT) images were reviewed to figure out the causes of the recurrence after SPAL. RESULTS: Among 75 patients, 53 (70.7%) were males. Male preponderance (80%) was more definite among those who have undergone SPAL (p=0.04). Age over 40 as well as the winter season and the underlying disease such as hypertension were also critical risk factors for posterior epistaxis. Four out of 35 patients who had undergone SPAL showed recurrence. The bleeding was detected in the branches of sphenopalatine artery in three out of the four patients who experienced recurrent bleeding following SPAL, which were controlled by revision surgery or arterial embolization. CONCLUSION: Posterior epistaxis occurred frequently in men over 40 years of age and in winter. A careful preoperative review of CT images and meticulous dissection during SPAL might be helpful for preventing recurrence after SPAL.

Epstein-Barr Virus Positive Primary Lymphoepithelial Carcinoma of the Parotid Gland with Hot Uptake of the Nasopharynx at Positron Emission Tomography-Computed Tomography / 대한이비인후과학회지

Lymphoepithelial carcinoma (LEC) is a rare histological type of cancer of the salivary glands. LEC is characterized histologically as non-keratinizing, undifferentiated squamous cell carcinoma with lymphocytic infiltration. According to several in-situ hybridization studies, LEC is strongly associated with Epstein-Barr virus (EBV) infection. We report, along with a review of literature, a rare case of EBV positive primary LEC of the parotid that excluded the possibility of coexisting or metastatic nasopharyngeal carcinoma.

A Case of Removal of Medial Maxillary Intraosseous Hemangioma through an Intranasal Endoscopic Prelacrimal Recess Approach / 대한이비인후과학회지

The intranasal endoscopic prelacrimal recess approach (PLRA) is a novel technique that was recently introduced for the management of maxillary sinus lesions. We utilized this approach for the surgical resection of a medial maxillary bony lesion; gross total resection was achieved without significant complications. The PLRA appears to be an effective and safe technique for the treatment of bony lesions of the maxilla as well as the maxillary sinus, particularly those confined to the medial maxillary wall.

Two-Phase Helical Computed Tomography Study of Salivary Gland Warthin Tumors: A Radiologic Findings and Surgical Applications

OBJECTIVES: The goal of this study was to define the radiologic characteristics of two-phase computed tomography (CT) of salivary gland Warthin tumors and to compare them to pleomorphic adenomas. We also aimed to provide a foundation for selecting a surgical method on the basis of radiologic findings. METHODS: We prospectively enrolled 116 patients with parotid gland tumors, who underwent two-phase CT preoperatively. Early and delayed phase scans were obtained, with scanning delays of 30 and 120 seconds, respectively. The attenuation changes and enhancement patterns were analyzed. In cases when the attenuation changes were decreased, we presumed Warthin tumor preoperatively and performed extracapsular dissection. When the attenuation changes were increased, superficial parotidectomy was performed on the parotid gland tumors. We analyzed the operation times, incision sizes, complications, and recurrence rates. RESULTS: Attenuation of Warthin tumors was decreased from early to delayed scans. The ratio of CT numbers in Warthin tumors was also significantly different from other tumors. Warthin tumors were diagnosed with a sensitivity of 96.1% and specificity of 97% using two-phase CT. The mean operation time was 38 minutes and the mean incision size was 36.2 mm for Warthin tumors. However, for the other parotid tumors, the average operation time was 122 minutes and the average incision size was 91.8 mm (P<0.05). CONCLUSION: Salivary Warthin tumor has a distinct pattern of contrast enhancement on two-phase CT, which can guide treatment decisions. The preoperative diagnosis of Warthin tumor made extracapsular dissection possible instead of superficial parotidectomy.

Immunohistochemical Study on beta1- and beta2-Adrenergic Receptors in Rat Vestibular Nuclei / 대한평형의학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to examine the localizations of beta1- and beta2-adrenergic receptors (ARs) in rat vestibular nuclei by immunohistochemical staining procedure. MATERIALS AND METHODS: Twelve male Sprague-Dawley rats were used in this study. Primary antibodies for the beta1- and beta2-ARs were used. The sections were treated with a biotinylated goat anti-rabbit antibody. The sections were then incubated in avidin-biotin-peroxidase reagent and processed with immunoperoxidase using 3.3'-diaminobenzidine tetrahydrochloride. RESULTS: beta1-AR and beta2-AR immunopositive neurons were found to be distributed throughout the four major vestibular nuclei. Both receptors were primarily detected in neuronal somata and their proximal dendrites. beta1-AR and beta2-AR were moderately expressed in the superior vestibular nucleus, lateral vestibular nucleus, medial vestibular nucleus, and spinal vestibular nucleus. CONCLUSION: The present study demonstrates, for the first time, that beta1-AR and beta2-AR receptors are localized in rat vestibular nuclei. Furthermore, this study may provide additional speculation into the role of ARs during vestibular signal processing. Further studies are needed to clarify the roles played by beta1-ARs and beta2-ARs through physiologic and functional studies.

Clinical Results of Endoscopic Endonasal Transsphenoidal Hypophysectomy during an Acceleration Phase of Learning Curve / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to compare endoscopic endonasal transsphenoidal hypophysectomy (EETSA) with microscopic transseptal transsphenoidal hypophysectomy (MTTSA) in terms of clinical results during an acceleration of learning curve. SUBJECTS AND METHOD: A retrospective chart review was performed of the first 14 cases of EETSA and previous 14 cases of MTTSA. Resection results, endocrinologic outcomes, complication rates, operating time, and duration of hospital stay were investigated. A non-parametric analysis was performed to determine the significance of differences between groups. RESULTS: EETSA was performed, achieving gross total removal, based on postoperative MRI, for 12 of the 14 patients (86%) and hormonal remission for 4 of the 5 patients (80%); on the other hand, MTTSA was performed, achieving gross total removal for 9 of the 14 patients (64%) and hormonal remission for 1 of the 5 patients (20%). We found better resection results in patients who underwent EETSA than in those who did MTTSA with respect to tumors extending into suprasellar area (p<0.05). Visual improvement was achieved in all the cases with visual defect (n=5) after EETSA, whereas 4 of 6 cases (66%) were improved after MTTSA. Significant differences in complication rates, operating time and hospital stay could not be determined. All cases with CSF leakage in EETSA were successfully managed by using the nasoseptal flap. CONCLUSION: EETSA provided better resection results than MTTSA did, especially in cases extending into the suprasellar area, showing good hormonal cure and visual improvement rates. Two approaches were comparable with respect to complications during the learning curve.

A Case of Desmoid-Type Fibromatosis That was Taken for Recurred Papillary Thyroid Cancer / 대한이비인후과학회지

Desmoid-type fibromatosis occurs rarely, especially in the head and neck region. It is a non-malignant neoplasm, has a good prognosis but sometimes occurs as local invasion. Complete excision surgery should carry out to reduce morbidity. In recurrent cases, supplemental radiotherapy and chemotherapy can be tried. We encountered a patient presenting desmoid-type fibromatosis which was misdiagnosis as a recurrent case of papillary thyroid cancer. Probably, the mass had occurred in that lesion because of the trauma of a previous thyroidectomy. We discuss this case with a review of literatures.

A Case of Minimal Invasive Follicular Carcinoma in Childhood / 대한이비인후과학회지

Minimally invasive follicular carcinoma is exceedingly rare in children and should be included in the differential diagnosis of thyroid mass. A 2-year-old child visited the hospital with a left neck mass. Ultrasonography showed a 3.5 cm-sized well-defined hypoechoic mass in the left lobe of thyroid gland and fine needle aspiration cytology revealed multiple benign follicular cells and a cluster of giant cell. He underwent left lobectomy and the subsequent histopathologic diagnosis confirmed the minimally invasive follicular carcinoma. He has been followed up for 12 months without any evidence of recurrence.

A Case of Isolated Multiple Cricoid Fracture Associated with Neck Trauma / 대한이비인후과학회지

Laryngeal trauma is relatively uncommon but can be possibly life-threatenning. An isolated cricoids fracture associated with neck trauma is rare. We report a case of an isolated multiple fragmented cricoid cartilage fracture that was developed in a 30-year-old man after a neck trauma. It was diagnosed by computed tomography and treated successfully.

A Case of Bilateral Pseudocyst of the Auricle / 대한이비인후과학회지

A pseudocyst of the auricle is a benign idiopathic, uncommon condition, which typically presents as a unilateral painless swelling over the anterior aspect of the auricle. If left untreated, the permanent deformity of the pinna may occur. Many modalities of treatment have been reported but the definitive treatment still remains controversial because of the high recurrence rate. It seems predominantly only one sided with most of the bilateral lesions developing asynchronously, and only a few cases have reported on simultaneous involvement of both pinna. We experienced a case of a 23-years-old man with an endochondral pseudocyst of simultaneous involvement of his both auricles. This is the first report in Korea, so we report this case with a review of the literature.

A Case of Bilateral Vocal Cord Paralysis in a Patient with Rheumatoid Arthritis / 대한이비인후과학회지

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting the synovial membrane and causing joint damage and bone destruction. The symptoms of cricoarytenoid joint (CJ) arthritis often include hoarseness, and a sense of pharyngeal fullness in the throat. Sometimes, in cases with bilateral CJ involvement, an urgent tracheostomy might be required for acute airway obstruction. In this report, we describe a 45-years-old man suffering from voice change and aspiration due to hampered adduction of the vocal fold that was caused by RA with bilateral CJ involvement. The medication treatment for RA was carried out and the patient retrieved her normal voice after one month.

Endoscopic Reconstruction of a Total Sella Defect with Nasoseptalflap

Cerebrospinal fluid (CSF) leakage is a possible major complication in skull base surgery. Application of the expanded endoscopic endonasal approach in skull base surgery expands the accessibility to resect skull base lesions but also increases the risk of CSF leakage due to the creation of larger dural defects in the skull base. Reconstruction of the skull base with multilayered autologous materials has been a key surgical technique. A recent advance in skull base reconstruction is nasoseptal flap, a robust reliable vascular pedicled flap supplied with the septal branch of the sphenopalatine artery. This technique has been reported to significantly decrease the risk of CSF leakage. We report a case of giant pituitary adenoma involving the suprasellar space and sphenoid sinus with a near total sellar defect. The lesion was removed using the endoscopic endonasal transsphenoidal approach, and the sellar floor was successfully reconstructed using a nasoseptal flap with no other multilayered support.