Defining Safety Space for Functional Tongue Surgery in Korean Male Obstructive Sleep Apnea Syndrome Patients; Analysis on Spatial Relation of the Tongue and the Lingual Artery / 대한이비인후과학회지

Background and Objectives@#Upon operation of the tongue base for obstructive sleep apnea syndrome (OSAS), the lingual artery and the hypoglossal nerve are put at risk of injury, resulting in fatal complications such as massive bleeding upon damage. We studied the course of lingual artery in its relation with the tongue in OSAS patients and compared it with the age-and- gender-matched normal population.Subjects and Method Korean male patients confirmed with OSAS by polysomnography, including those who had contrast-enhanced computed tomography (ceCT) of the head and neck, were defined as “OSAS group.” Patients who had their ceCT image during the same study period were defined as the “control group.” The control group was paired with the OSAS group by age and sex. By using foramen cecum (FC) as the main reference point, four reference marks were defined. For each reference point, the distance between both lingual arteries and the depth of the lingual artery from the lingual surface of the tongue were evaluated. @*Results@#The depth of the lingual artery from the lingual surface of the tongue in the OSAS group (25.1±8.6 mm) was significantly different from the control (29.5±5.9 mm) at 1 cm anterior to the FC level (p<0.014). The width of both lingual arteries was narrower in the OSAS group (20.9±2.9) than in the control (24.3±6.1) at the FC level (p<0.003). @*Conclusion@#The course of lingual artery and its spatial relation with the tongue in Korean male OSAS patients differs from the matched normal population.

Three Cases of Nasal Chondromesenchymal Hamartoma Occurred in Sinonasal Tract / 대한이비인후과학회지

Nasal chondromesenchymal hamartoma (NCMH) is a rare benign tumor of the sinonasal tract. Most NCMH has a benign nature and can be cured by complete resection. Only a few NCMH cases have been reported worldwide due to its rarity. Here, we report three cases of successfully treated NCMH, of which one case was diagnosed during preliminary ultrasound. All three cases were consistent with the benign symptoms of NCMH. Tumor in all of the cases were successfully treated through an endoscopic approach surgery and no evidence of aggressive recurrence was reported.

Does Rapid Eye Movement Sleep Aggravate Obstructive Sleep Apnea?

OBJECTIVES.: To investigate the apnea-hypopnea index (AHI) according to the sleep stage in more detail after control of posture. METHODS.: Patients who underwent nocturnal polysomnography between December 2007 and July 2018 were retrospectively evaluated. Inclusion criteria were as follows: age >18 years, sleep efficacy >80%, and patients who underwent polysomnography only in the supine position (100% of the time). Patients were classified into different groups according to the methods: the first, rapid eye movement (REM)-dominant group (AHIREM/AHINREM >2), non-rapid eye movement (NREM)-dominant group (AHINREM/AHIREM >2), and non-dominant group; and the second, light sleep group (AHIN1N2>AHISWS) and slow wave sleep (SWS) group (AHISWS>AHIN1N2). RESULTS.: A total of 234 patients (mean age, 47.4±13.9 years) were included in the study. There were 108 patients (46.2%) in the REM-dominant group, 88 (37.6%) in the non-dominant group, and 38 (16.2%) in the NREM-dominant group. The AHI was significantly higher in the NREM-dominant group than in the REM-dominant group (32.9±22.9 events/hr vs. 18.3±9.5 events/hr, respectively). There were improvements in the AHI from stage 1 to SWS in NREM sleep with the highest level in REM sleep. A higher AHISWS than AHIN1N2 was found in 16 of 234 patients (6.8%); however, there were no significant predictors of these unexpected results except AHI. CONCLUSION.: Our results demonstrated the highest AHI during REM sleep stage in total participants after control of posture. However, there were 16.2% of patients showed NREM-dominant pattern (AHINREM/AHIREM >2) and 6.8% of patients showed higher AHISWS than AHIN1N2. Therefore, each group might have a different pathophysiology of obstructive sleep apnea (OSA), and we need to consider this point when we treat the patients with OSA.

A Case of Respiratory Arrest after Tonsillectomy and Adenoidectomy Surgery in a Patient with Rubinstein-Taybi Syndrome / 대한이비인후과학회지

Rubinstein-Taybi syndrome (RTS) is a rare autosomal dominant disorder characterized by mental and growth retardation, craniofacial, vertebral, ocular and cardiac anomalies, gastro-esophageal reflux, and difficult airway management. Patients with this syndrome can also experience upper airway obstruction during sleep, which is caused by hypotonia and the abnormal anatomy of the oropharynx and airways, and become susceptible to obstructive sleep apnea. In our case, respiratory arrest developed in an RTS patient who had undergone Tonsillectomy and Adenoidectomy (T&A) surgery. It is the first report of respiratory arrest after T&A surgery in a young child with RTS.

Three Cases of IgG4-Related Sclerosing Disease in Nasal Cavity

IgG4-related sclerosing disease (IgG4-RSD) is characterized by extensive IgG4-positive plasma cell and T-lymphocyte infiltration of various organs. However, the nasal cavity is an extremely rare site of involvement. The authors experienced three cases of igG4-RSD in the nasal cavity. A 54-year-old woman presented with a nasal cavity mass on endoscopic exam and computed tomography (CT) revealed not only a hypoenhancing mass in the right nasal cavity but also a pituitary gland macroadenoma. Endoscopic removal and endoscopic TSA were performed. A 20-year-old man diagnosed with chronic sinusitis, underwent endoscopic sinus surgery. A 26-year-old woman showed thickening of the nasal septum and cribriform plate, and an infiltrating soft tissue lesion in right the alveolar process on CT and an endoscopic biopsy was performed. Pathologic specimens of all cases showed IgG4-positive plasma cell infiltration, consistent with IgG4-RSD. Serum IgG4 levels were checked in two of the cases, and the results were within normal range. All cases were further treated with methylprednisolone and all showed clinical improvement.

Five-Year Subjective Outcomes of Obstructive Sleep Apnea Surgery: A Multiinstitutional Study

OBJECTIVES: To evaluate the effect of obstructive sleep apnea (OSA) surgery on long-term (5-year) subjective outcomes, including sleep disordered breathing (SDB) symptoms and other complications, in patients with OSA. METHODS: We enrolled patients who underwent diagnostic polysomnography for OSA between January 2006 and December 2006 in ten hospitals. Patients either were treated for OSA or were not treated for OSA. All patients completed a brief telephone survey regarding their SDB signs and symptoms (e.g., snoring, apnea, nocturnal arousals, and daytime sleepiness), positive airway pressure (PAP) compliance, and any adverse effects of either the surgery or PAP. A positive subjective outcome for either surgery or no treatment was taken to be the alleviation of apnea, defined as a > or =50% increase in score. A positive subjective outcome (compliance) for PAP was defined as a PAP usage of > or =4 hours per night and > or =5 days per week. RESULTS: A total of 229 patients were included in this study. Patients were divided into three groups: a surgery group (n=87), a PAP group (n=68), and a control (untreated) group (n=74). The surgery group exhibited significant improvement in all SDB symptoms compared with the control group. The long-term subjective outcomes of the surgery (52.9%) and PAP (54.4%) groups were significantly better than those of the control group (25.0%). The subjective outcome of the surgery group was not significantly different from that of the PAP group. The overall surgical complication rate was 23.0% (20 of 87) in the surgery group, and 55.0% (22 of 40) of all patients with PAP experienced adverse effects. CONCLUSION: The extent of SDB symptoms was consistently improved in patients with OSA at 5 years postsurgery. Information about the potential long-term subjective outcomes should be provided to patients when considering surgery.

The Utility of Three Screening Questionnaires for Obstructive Sleep Apnea in a Sleep Clinic Setting

PURPOSE: The aim of this study was to determine the diagnostic value of three screening questionnaires in identifying Korean patients at high risk for obstructive sleep apnea (OSA) in a sleep clinic setting in Korea. MATERIALS AND METHODS: Data were collected from 592 adult patients with suspected OSA who visited a sleep center. All patients completed the Sleep Apnea of Sleep Disorder Questionnaire (SA-SDQ), the Berlin questionnaire, and the STOP-Bang questionnaire. Estimated OSA risk was compared to a diagnosis of OSA. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each questionnaire. RESULTS: The prevalence of OSA was 83.6% using an apnea-hypopnea index (AHI) > or =5/h and 58.4% for an AHI > or =15/h. The STOP-Bang questionnaire had a high sensitivity (97% for AHI > or =5/h, 98% for AHI > or =15/h), but the specificity was low (19% and 11%, respectively). In contrast, the sensitivity of the SA-SDQ was not high enough (68% for AHI > or =5/h, 74% for AHI > or =15/h) to be useful in a clinical setting, whereas the specificity was relatively good (66% and 61%, respectively). The sensitivity and specificity values of the Berlin questionnaire fell between those of the STOP-Bang questionnaire and the SA-SDQ. CONCLUSION: The STOP-Bang questionnaire may be useful for screening OSA in a sleep clinic setting, but its specificity is lower than the acceptable level for this purpose. A new screening questionnaire with a high sensitivity and acceptable specificity is therefore needed in a sleep clinic setting.

Engagement of CD99 Reduces AP-1 Activity by Inducing BATF in the Human Multiple Myeloma Cell Line RPMI8226

CD99 signaling is crucial to a diverse range of biological functions including survival and proliferation. CD99 engagement is reported to augment activator protein-1 (AP-1) activity through mitogen-activated protein (MAP) kinase pathways in a T-lymphoblastic lymphoma cell line Jurkat and in breast cancer cell lines. In this study, we report that CD99 differentially regulated AP-1 activity in the human myeloma cell line RPMI8226. CD99 was highly expressed and the CD99 engagement led to activation of the MAP kinases, but suppressed AP-1 activity by inducing the expression of basic leucine zipper transcription factor, ATF-like (BATF), a negative regulator of AP-1 in RPMI8226 cells. By contrast, engagement of CD99 enhanced AP-1 activity and did not change the BATF expression in Jurkat cells. CD99 engagement reduced the proliferation of RPMI8226 cells and expression of cyclin 1 and 3. Overall, these results suggest novel CD99 functions in RPMI8226 cells.

Prevention of wrong site, wrong procedure, wrong patient surgery and time-out

While errors in surgical site or patient identification should not occur, they are some of the most common sentinel events. These events affect not only the patient but also the surgeon and hospital. The exact incidence of surgical errors cannot be measured because measurement depends on voluntary reporting. There have been many efforts to reduce these surgical errors. For example, Universal protocol and time-out just before surgery begins have been introduced. It is also essential to mark the surgical site in a uniform manner. Despite these processes,surgical errors still happen for many reasons. One of most common root causes is communication error. It is essential to use precise communication and to speak up if something is wrong. Hospitals and surgeons should use leadership to involve their teams in a patient safety culture. Not only the system but also this patient safety culture can reduce the incidence of surgical error.

Surgical Treatment of Obstructive Sleep Apnea Syndrome / 대한내과학회지

Continuous positive airway pressure (CPAP) has proven very effective in the treatment of adult obstructive sleep apnea syndrome (OSAS). However, the CPAP device must be used every day and is associated with some discomfort. As a result, many patients do not comply with physician-recommended CPAP usage. Surgical intervention for OSAS eliminates issues with patient non-compliance. Although it is less effective than CPAP, surgery represents a feasible alternative for patients who are non-compliant with CPAP usage, have mild to moderate OSAS without significant comorbidities, or suffer from simple snoring. Nasal surgery can also reduce an individual's CPAP pressure requirement and thus increase compliance. Of the various surgical procedures available, uvulopalatopharyngoplasty, which removes excess tissue from the soft palate and pharynx, is successful only in selected patients, while multilevel surgery is more effective. For example, maxillomandibular advancement is promising, although it is associated with potential morphological change in the airway. Radiofrequency ablation and palatal implants are minimally invasive interventions for simple snoring and mild OSAS. In morbidly obese patients, bariatric surgery has proven particularly effective. Finally and most recently, surgically implanted devices that stimulate the hypoglossal nerve have been investigated.

Risk Factors for Mortality in Patients with Invasive Mucormycosis / 감염과화학요법

BACKGROUND: Mucormycosis is an uncommon and life-threatening fungal infection. The clinical predictors of outcome were evaluated in patients with invasive mucormycosis. MATERIALS AND METHODS: We retrospectively reviewed histologically proven cases of invasive mucormycosis in our institution from 1996 to 2012. RESULTS: A total of 64 patients were analyzed. The median age was 59 years (interquartile range [IQR], 50-67), and 32 patients (50%) were male. The most common underlying diseases were diabetes mellitus (67%), hematologic malignancy (22%), and solid cancer (19%). The most common infection sites were the rhino-orbito-cerebral area (56%) and the lungs (31%). The 180-day all-cause mortality was 33%. Disseminated infection was associated with increased mortality (hazard ratio [HR]: 169.74, 95% confidence interval [CI]: 6.41 to 4492.64; P = 0.002). Pulmonary infection (HR: 0.08, 95% CI: 0.01 to 0.66; P = 0.02) and complete surgical removal of infected tissue (HR: 0.12, 95% CI: 0.02 to 0.64; P = 0.01) were associated with decreased mortality. CONCLUSIONS: These results suggest that patients with mucormycosis had a lower risk of mortality if they developed a pulmonary infection, rather than a disseminated infection and with complete debridement of infected tissue.

Diagnosis of Obstructive Sleep Apnea Syndrome / 한양의대학술지

Obstructive sleep apnea is a prevalent disease and contributes to consequences like hypertension, diabetes, stroke, cardiac disease, daytime sleepiness, decreased productivity, mood change, and quality of life. The mortality and morbidity due to consequences are related to severity of obstructive sleep apnea. The severity of obstructive sleep apnea is measured by apnea-hypopnea index or respiratory disturbance index. The diagnosis of obstructive sleep apnea is made by polysomnographic findings and/or one of its symptoms (daytime symptoms like unintentional sleep episode during wakefulness, daytime sleepiness, unrefreshing sleep, insomnia, or fatigue, nighttime symptoms like breath holding, gasping, or choking, or bed partner's report about loud snoring, breath stopping). Due to high cost, inconvenience, and availability of in-lab polysomnogrpahy, simple diagnostic tools are suggested. Portable polysomnography has advantages including low cost, home monitoring, and convenience. But portable polysomnography has limitations like safety issues, lead malfunction, sensitivity, and specificity. Moreover, in some patients, portable polysomnography cannot be applied. The standard suggested diagnostic methods and available alternative tools are reviewed.

Clinical Features and Treatment Results of 64 Cases of Nasolabial Cyst

BACKGROUND AND OBJECTIVES: Nasolabial cysts are relatively rare and are sometimes confused with tumors due to progressive enlargement. Treatment of a nasolabial cyst consists of sublabial excision or endonasal endoscopic marsupialization (EEM). The purpose of this study was to investigate the clinical features of nasolabial cysts in order to provide a basis for correct diagnosis and treatment. MATERIALS AND METHODS: Sixty-four patients with a nasolabial cyst were surgically treated between December, 1989 and January, 2010 at the Department of Otolaryngology, Asan Medical Center. Their clinical features, radiologic and histopathologic findings, and treatment and outcomes were retrospectively analyzed. RESULTS: The patients comprised 51 (80%) women and 13 men (20%), with ages ranging from 16 to 69 years with a mean of 43 years. Swelling of the nasolabial fold was the most frequently experienced symptom. There was no right or left side preponderance. Sublabial excision was applied in 57 cases (89%), while seven cases (11%) were treated via the endonasal approach. There was no case of recurrence. CONCLUSION: Nasolabial cysts should be suspected in patients with swelling of the nasolabial area and nasal obstruction. Enhanced CT may be needed to differentiate from tumors, odontogenic cysts, or other inflammatory lesions. Nasolabial cysts can be successfully treated via sublabial or endonasal approaches. Postoperative complications or recurrence is very rare.

Morphological characteristics of the upper airway and pressure drop analysis using 3D CFD in OSA patients / 대한치과교정학회지

OBJECTIVE: Obstructive sleep apnea (OSA) is a common disorder which is characterized by a recurrence of entire or partial collapse of the pharyngeal airway during sleep. A given tidal volume must traverse the soft tissue tube structure of the upper airway, so the tendency for airway obstruction is influenced by the geometries of the duct and characteristics of the airflow in respect to fluid dynamics. METHODS: Individualized 3D FEA models were reconstructed from pretreatment computerized tomogram images of three patients with obstructive sleep apnea. 3D computational fluid dynamics analysis was used to observe the effect of airway geometry on the flow velocity, negative pressure and pressure drop in the upper airway at an inspiration flow rate of 170, 200, and 230 ml/s per nostril. RESULTS: In all 3 models, large airflow velocity and negative pressure were observed around the section of minimum area (SMA), the region which narrows around the velopharynx and oropharynx. The bigger the Out-A (outlet area)/ SMA-A (SMA area) ratio, the greater was the change in airflow velocity and negative pressure. CONCLUSIONS: Pressure drop meaning the difference between highest pressure at nostril and lowest pressure at SMA, is a good indicator for upper airway resistance which increased more as the airflow volume was increased.

Treatment Results of 111 Cases of Antrochoanal Polyp

BACKGROUND AND OBJECTIVES: Antrochoanal polyp (ACP) is a benign maxillary sinus polyp that originates from the mucosa of the maxillary sinus, passes through the sinus ostium, and extends into the choana. Surgical methods employed in the treatment of antrochoanal polyp are simple avulsion, Caldwell-Luc operation, osteoplastic maxillary sinus operation, and endonasal endoscopic removal. In this study, we evaluated the clinical presentation of ACP and compared its surgical outcomes. MATERIALS AND METHODS: We retrospectively reviewed 111 patients who were treated for ACP between January 1995 and May 2008, and analyzed clinical features, radiologic findings, and surgical results. RESULTS: The study group consisted of 111 patients (65 males, 46 females) with a mean age of 20.0 years (range, 4 to 70). Sixty-one cases were accompanied by sinusitis (20 with unilateral sinusitis, 41 with bilateral sinusitis). Endoscopic sinus surgery (ESS) was used to treat 95 cases, and the external approaches of Caldwell-Luc operation or osteoplastic maxillary sinus operation were applied in 12 and four cases, respectively. Among those who received ESS, ACP recurred in 16 cases, whereas none of the patients who received the external approach showed recurrence. CONCLUSION: Endoscopic sinus surgery is a good alternative method for the treatment of ACP. If the antral part of ACP cannot be removed completely, an external approach such as Caldwell-Luc operation or osteoplastic maxillary sinus operation for pediatric patients may be considered to prevent recurrence.

The Effect of Uvula-Preserving Palatopharyngoplasty in Obstructive Sleep Apnea on Globus Sense and Positional Dependency

OBJECTIVES: This study investigated the outcomes of uvula-preserving palatopharyngoplasty (UPPPP) in patients with obstructive sleep apnea syndrome (OSAS). METHODS: Twenty men with obstructive sleep apnea syndrome received the UPPPP operation at our institution. We measured symptom changes after UPPPP using a visual analog scale (VAS), and all patients were examined with polysomnography pre- and post-operatively. 'Surgical success' was defined as reduction in apnea-hypopnea index (AHI) to below 20 events per hour and more than 50% post-operative reduction. RESULTS: Snoring decreased significantly (6.7+/-2.3 to 3.7+/-2.9 on VAS, P=0.002) but the postoperative globus sense did not differ from that preoperatively (2.0+/-2.4 to 2.1+/-2.7 on VAS, P=0.79). Apnea and apnea-hypopnea indices were significantly reduced after UPPPP (34.7+/-20 to 24.2+/-17.2 events/hour, P=0.029). The surgical success rate was 40% regardless of Friedman stage. There was significant reduction in the AHI on supine sleep in both surgically successful and unsuccessful patient groups. CONCLUSION: UPPPP may minimize postoperative globus sense and other complications, with a success rate comparable to that of previously reported surgical methods in OSAS patients. In addition, it may reduce the apnea-hypopnea index in the supine sleep position.

Sleep Medicine and Public Health / 대한이비인후과학회지

Sleep and public health has close relationship. Life in modern society makes human sleep deprived state. Sleep deprivation could induce cognitive deficits, heart diseases, glucose metabolic disorders, and decrease quality of life. Moreover, shift worker should work in mismatched circadian rhythm environment. Errors due to sleep deprivation, mismatched circadian rhythm, and various sleep disorders including sleep apnea could be tremendous hazard to public. By understanding sleep physiology, we can prevent sleep deprivation induced accidents and health problems. Sleep specialists have role of education and detection of patients with sleep disorders

Reduced Mitochondrial Properties in Putative Progenitor/Stem Cells of Human Keratinocytes

BACKGROUND: The characterization of progenitor/keratinocyte stem cells (KSC) remains an unachieved goal. A previous study showed that rapid adhering cells to collagen IV had the characteristics of putative progenitor/KSCs. OBJECTIVE: The purpose of this study was to investigate the genetic expression of rapid adhering cells compared to non adhering cells to determine the characteristic of KSCs. METHODS: We isolated rapid adhering cells representative of KSCs from non adhering cells representative of transient amplifying cells. In addition, we differentiated cells from human tonsilar keratinocytes utilizing the adhering capability of the KSCs to collagen IV. Annealing control primer based differentially displayed polymerase chain reaction (PCR) was performed as well as Western blot analysis. RESULTS: The levels of mitochondria-related gene expression were low in the rapid adhering cells compared to the non adhering cells. Mitochondrial complex I, COX IV, peroxiredoxins (I, II and IV) and mitochondrial membrane potential were all low in the rapid adhering cells compared to the non adhering cells. CONCLUSION: Using an adhesion method on human collagen IV-coated plates, our results suggest that reduced mitochondrial function may be an important characteristic of KSCs.

Compliance with Positive Airway Pressure Treatment for Obstructive Sleep Apnea

OBJECTIVES: Positive airway pressure (PAP) is considered a standard treatment for moderate-to-severe obstructive sleep apnea (OSA) patients. However, compliance with PAP treatment is suboptimal because of several types of discomfort experienced by patients. This study investigated compliance with PAP therapy, and affecting factors for such compliance, in OSA patients. METHODS: We performed a survey on 69 patients who engaged in PAP therapy between December 2006 and November 2007. After diagnostic polysomnography and manual titration, patients trialed PAP using the ResMed instrument and explored autoadjusting PAP (APAP), continuous PAP (CPAP), and flexible PAP (using expiratory pressure relief [EPR]) at least once every week for 1 month. Compliance measures were mean daily use (hr), percentage of days on which PAP was used, and percentage of days on which PAP was used for >4 hr. Data were obtained at night using the software Autoscan version 5.7(R) of the ResMed Inc. We obtained data on anthropometric (age, BMI, neck circumflex, Epworth sleepiness scale, Pittsburgh Sleep Quality Index, hypertension, alcohol intake), polysomnographic data (severity of apnea-hypopnea index [AHI], proportion of nonsupine sleep time, position dependence of sleep), PAP mode and AHI during PAP use for affecting factors. RESULTS: After 1 month, 41 of the 69 patients (59.4%) were pleased with PAP therapy and purchased instruments. Twenty-four patients (34.7%) used PAP for more than 3 months. The percentage of days on which PAP was used was statistically higher in patients with hypertension than in normotensive patients (P=0.003). There were negative correlations 1) between nonsupine position sleep time and percentage of days on which PAP was used (r=-0.424, P=0.039), and 2) between the AHI during PAP use and the percentage of days on which PAP was used for >4 hr (r=-0.443, P=0.030). There were no statistical differences between AHI, BMI, PAP pressure, or other measured parameters, on the one hand, and compliance, on the other. CONCLUSION: The affecting factors for PAP use were hypertension history, sleep posture (shorter nonsupine sleep time), and lower AHI during PAP use.

Pathogenesis of Obstructive Sleep Apnea

Obstructive sleep apnea has a close relationship with the anatomical characteristics of the upper airway. But we should consider that obstructive sleep apnea always occurs only when the patients are asleep. Diminishing of neural signal to pharyngeal dilator muscles during the sleep state has a great role in the pathogenesis of obstructive sleep apnea. Narrowing of the upper airway could be due to aging, abnormality of craniofacial skeleton, obesity, narrowing of nasal cavity, adhesive force of mucosa, gravity, sleep, vibratory trauma of upper airway when snoring, compliance of pharyngeal dilator muscle, and apnea threshold according to blood carbon dioxide concentration. Understanding of these possible causes may help to develop treatment modality for obstructive sleep apnea and to introduce individual treatment.