A Case of Mantle Cell Lymphoma with Meningioma / 대한소화기학회지

Mantle cell lymphoma (MCL) is an uncommon type of gastrointestinal lymphoma. MCL is a distinct subtype of B-cell non-Hodgkin lymphomas. The major subtype of MCL is characterized by the presence of multiple lymphomatous polyposis (MLP), in which multiple polyps are observed along the gastrointestinal tract. The malignant cells express pan B-cell marker and the T-cell marker cluster of differentiation 5. The chromosomal translocation t(11;14)(q13;q32) that causes cyclin D1 overexpression is commonly observed on the cytogenetic analysis of MCL. Survival improvement has recently been achieved for patient with MCL by the successful introduction of monoclonal antibodies and dose-intensified approaches for treatment, including autologous stem cell transplantation strategies. Some reports suggest that there is an increased incidence of second malignancies in patients with MCL or lymphoma. We report a case of MCL involving the colon; the patient was a 60-year-old man who complained of low abdominal discomfort during defecation. During the workup, a meningioma was unexpectedly discovered. On analysis, the tumor was found to be a t(11;14)-negative and non-MLP-type MCL.

A Case of Needle-Track Implantation of Hepatocellular Carcinoma in the Chest Wall after Laparoscopic Radiofrequency Ablation / 대한내과학회지

Radiofrequency ablation (RFA) is a popular technique and shows excellent local tumor control and acceptable morbidity. Although RFA is considered much safer than surgical treatment, it is not a complication-free procedure. The most common complications of percutaneous RFA areabdominal hemorrhage, abdominal infection (abscess), biliary tract damage, and ground-pad burns. Laparoscopic RFA (LRFA) is a safe, feasible treatment modality to achieve tumor destruction. LRFA has proven superior to the percutaneous approach for lesions that are difficult or impossible to treat percutaneously. Needle-track implantationafter LRFA is a rare complication in HCCs. We report a case of needle-tract implantation of HCC found in the chest wall, ribs,and diaphragm 11 months after LRFA in a 49-year-old man. Although treatment for needle-track implantation is not well established, the metastatic mass was surgically removed.

A Case of Gastric Lymphoepithelioma-like Carcinoma Presenting as Panperitonitis by Perforation of Stomach / 대한소화기학회지

Gastric lymphoepithelioma-like carcinoma is a rare carcinoma among gastric malignant tumor but has a good prognosis. The carcinoma has histologic feature characterized by small nest of cancer cells mixed with lymphoid stroma. We report a case with lymphoepithelioma-like carcinoma of stomach initially presenting as panperitonitis because of spontaneous tumor perforation. A 56-year-old man visited our emergency room because of epigastric pain. A preoperative abdominal CT scan showed a massive pneumoperitoneum in the upper abdomen, and the presence of gastric cancer in the lesser curvature of the stomach. An emergent laparotomy was performed followed by radical subtotal gastrectomy. Pathologic examination revealed that the tumor was a lymphoepithelioma-like gastric carcinoma.

Importance of Medication Adherence to Peginterferon-Ribavirin Combination Therapy in Patients with Chronic Hepatitis C / 대한소화기학회지

BACKGROUND/AIMS: The combination therapy with peginterferon and ribavirin is a standard treatment for patients with chronic hepatitis C. However, because of the long duration of the treatment and many complications, the reduction of adherence frequently occur. This study aimed to assess influences of reduced medication adherence in the combination therapy of chronic hepatitis C patients. METHODS: We retrospectively reviewed the medical records of 82 patients with chronic hepatitis C who received a combination therapy with peginterferon and ribavirin. The patients were categorized into 3 subgroups on the basis of medication adherence. Group 1 comprised patients who received > or =80% of the recommended dosage of both peginterferon and ribavirin. Group 2 comprised those patients who received > or =80% of the recommended dosage of only 1 drug. The patients of Group 3 received <80% of the recommended dosage of both the drugs. RESULTS: Sustained virologic response (SVR)s of patients in Group 1, 2 and 3 were 85.4% (41/48), 85.7% (18/21), and 38.5% (5/13), respectively (p=0.002). SVRs of genotype 1 patients in Group 1, 2 and 3 were 84.2% (16/19), 75% (9/12), and 14.3% (1/7) , respectively (p=0.003). SVRs of genotype non-1 patients in Group 1, 2 and 3 were 86.2% (25/29), 100% (9/9), and 66.7% (4/6), respectively (p=0.196). Furthermore are SVRs significantly differed with the degree of medication adherence to either peginterferon or ribavirin (p=0.003 and 0.021, respectively). In multivariate analysis, the peginterferon dose was a significant independent factor associated with SVR. CONCLUSIONS: Medication adherence of chronic hepatitis C patients to the combination therapy with peginterferon and ribavirin is very important for achieving SVR. In particular, we think that genotype 1 patients should maintain higher adherence than genotype non-1 patients.

A Case of a Retroperitoneal Schwannoma Presenting as Hypermetabolic Mass in PET-CT / 대한소화기학회지

Schwannoma is a benign neoplasm of the Schwann cells of the neural sheath. Most schwannomas occur in the head and neck, and extremities and rarely in the retroperitoneal space. The differentiation of a schwannoma from other malignant tumor or benign tumor is very difficult on a preoperative examination with ultrasonography, computed tomography or magnetic resonance imaging. Furthermore, the lesion with increased fluorodeoxyglucose uptake in PET-CT cannot exclude malignant tumor. Therefore, this lesion needs surgical excision and a histological examination with immunohistochemical staining. We report a case of schwannoma occuring in the retroperitoneal space that incidentally discovered by PET-CT for health-check up. Pathologic confirmation by laparoscopic excision was done.

Comparison of the Toxicities and Efficacies of the Combination Chemotherapy Regimens in Advanced Gastric Cancer Patients Who Achieved Complete Response after Chemotherapy / 대한소화기학회지

BACKGROUND/AIMS: We retrospectively analyzed comparative toxicities and efficacies of chemotherapy regimens in advanced gastric cancer (AGC) patients who achieved complete response (CR) after chemotherapy. METHODS: We reviewed the medical records of 1,203 patients, who were pathologically diagnosed as AGC in a single center between January 2001 and October 2007. On the basis of the Response Evaluation Criteria in Solid Tumors, CR was evaluated with abdominal computed tomography. Toxicities were evaluated using the National Cancer Institute's common toxicity criteria before each chemotherapy cycle. RESULTS: Among the 1,203 AGC patients enrolled in this study, 568 received chemotherapy and 635 received best supportive care. The major chemotherapy regimens were 5-fluorouracil, leucovorin and oxaliplatin (FOLFOX), docetaxel, cisplatin and 5-fluorouracil (DCF) and 5-fluorouracil, leucovorin and irinotecan (FOLFIRI). Among the 568 patients, 51 (9.0%) achieved CR (49 [8.6%] with FOLFOX [n=12], DCF [n=26], or FOLFIRI [n=11] and 2 [0.3%] with etoposide, leucovorin and 5-fluorouracil). For patients administered FOLFOX, DCF, and FOLFIRI, the median time to disease progression was 4 months (range, 1.8-59.5), 15 months (range, 2.9-31.2) and 10 months (range, 2.0-39.5), and the median survival times were 48 months (range, 5.9-74.0), 37 months (range, 14.0-86.0), and 30 months (range, 6.0-50.0), respectively. Grades 3-4 mucositis occurred mostly in patients administered DCF (n=8, 30.8%). Grades 3-4 leucopenia were observed in 1 (8.3%), 11 (42.3%), and 4 (36.4%) patients administered FOLFOX, DCF and FOLFIRI, respectively. No statistically significant differences were observed in the 3 regimens. CONCLUSIONS: All 3 regimens (FOLFOX, DCF and FOLFIRI) were active and tolerable. Their efficacies and toxicities were not significantly different.

Clinical Outcomes of Endoscopic Submucosal Dissection for Undifferentiated or Submucosal Invasive Early Gastric Cancer

BACKGROUND/AIMS: Early gastric cancer (EGC) that is undifferentiated or shows submucosal invasion has not been generally accepted as an indication for endoscopic treatment. But recently, experiences with endoscopic submucosal dissection (ESD) for undifferentiated EGC or submucosal invasive (SM) EGC have increased. The aim of this study was to evaluate clinical outcomes of ESD for EGC with undifferentiation or submucosal invasion. METHODS: Between August 2005 and August 2009, among 210 EGCs treated using ESD at our hospital, 18 lesions were diagnosed as undifferentiated gastric cancer and 41 as SM gastric cancer. A retrospective analysis was done on the medical records of these patients. RESULTS: Mean follow-up periods were 19.39+/-11.2 months. During the follow-up period, local recurrence was noted in 4 lesions. Local recurrence rates of the EGC groups (group 1, mucosal cancer with undifferentiation; group 2, SM cancer with differentiation; group 3, SM cancer with undifferentiation) were 10%, 4.5%, and 50%, respectively. Groups 1 and 2 were not significantly different in local recurrence rates compared to the mucosal cancer with differentiation group (p=0.061, p=0.125, respectively). The undifferentiated EGC group was significantly lower in curability using ESD than the differentiated EGC group (55.6% vs. 89.6%, p=0.000). The curability of the SM EGC group was lower than the mucosal EGC group (36.6% vs. 98.9%). CONCLUSIONS: Complete resection using ESD is difficult in undifferentiated and SM gastric cancers. SM cancer with undifferentiation should be treated immediately by salvage operation. For mucosal cancer with undifferentiation or SM cancer with differentiation, one should consider careful short-term follow-up.

A Case of Gastric Undifferentiated Carcinoma with Choriocarcinomatous and Hepatoid Carcinomatous Differentiation / 대한소화기내시경학회지

Here we report a case of a patient with gastric undifferentiated carcinoma associated with choriocarcinomatous and hepatoid carcinomatous differentiation. A 62-year-old man was referred after a healthcare screening gastroscopy. Gastroscopy revealed an approximately 3x3 cm ulcerofungating mass in the posterior wall of the antrum. Biopsy results revealed a moderately differentiated adenocarcinoma. The initial serum alpha-FP levels were above 350 ng/mL. An abdominal CT scan revealed focal wall thickening along the greater curvature of the gastric antrum, with perigastric fat invasion and enlarged multiple perigastric lymph nodes. He underwent a palliative radical subtotal gastrectomy and gastroduodenostomy with dissection of the enlarged lymph nodes. Postsurgical histological examination revealed an undifferentiated carcinoma associated with choriocarcinomatous and hepatoid carcinomatous differentiation. Immunohistochemical staining revealed that the tumor cells were positive for human chorionic gonadotropin (hCG), alpha-FP, and anti-hepatocyte antibody.

Reduction Umbilicoplasty: A Simple and Effective Method

Many ideal definitions have been proposed about the desirable shape and position of the appealing umbilicus. The attractive umbilicus is a moderately small umbilical size with an overall vertical orientation We would like to propose a new, simple and effective technique to correct a abnormal distorted large protruding umbilicus which developed on a 43 year-old man who undergone previous surgery. A inner circle 1cm in diameter, which was generally considered as a normal size, was drawn in the center of deformed umbilicus. Another outer circle, which was drawn between normal abdomen and deformed umbilicus, was horizontally divided into 2 portions. The upper portion of the outer ring was excised down to the dermal area and lower portion was deepithelized. The inner circle flap was meticulously defatted down to the abdominal wall fascia. Then, this inner circle was fixed to the fascia with 3-0 monofilament sutures at 3,9,12 o'clock direction for making a superior hood. Remnant outer circle was closed primarily with adjacent proper undermining. The natural looking umbilicus was shown until postoperative 2 weeks. A longitudinal deep umbilical depression was cosmetically pleasing. This new method of reduction umbilicoplasty is a safe, simple, and effective technique for aesthetically pleasing umbilicus.

Staged Correction of Cicatricial Upper Eyelid Retraction and Contralateral Upper Eyelid Ptosis

Upper eyelid retraction may result in conjunctival and corneal exposure as well as a cosmetic problem. Ptosis can disrupt vision and makes it difficult to carry out everyday activities such as reading or driving. Although various surgical methods for correction of upper eyelid retraction and ptosis have been reported, correction of cicatricial upper eyelid retraction and contralateral ptosis in a patient still remains a challenging problem. We performed a staged procedure with a 6-month interval for correction of cicatricial upper eyelid retraction and contralateral ptosis with satisfactory results. A 21-year-old male patient presented with right upper eyelid retraction due to a previous lacerated wound and left upper eyelid ptosis. At first, levator recession and adhesiolysis via a skin incision were performed to correct the right eyelid retraction. About 6 months later, Muller tucking was done to correct the left eyelid ptosis. Patient's postoperative course was uneventful without any complications. At 1 month follow-up, the patient revealed excellent results from both functional and cosmetic point of view. Therefore, a careful surgical approach is needed for correction of cicatricial upper eyelid retraction and contralateral ptosis.

Pedicled Deep Inferior Epigastric Perforator Flap for Treatment of Dystrophic Epidermolysis Bullosa-Associated Squamous Cell Carcinoma in the Groin: Case Report

PURPOSE: Epidermolysis bullosa is a rare genetic disease, characterized by the presence of extremely fragile skin and formation of recurrent blister resulting from even a minor mechanical injury. Squamous cell carcinoma (SCC) is recognized as a complication of the chronic scarring associated with dystrophic epidermolysis bullosa (DEB). When a soft tissue defect happens in a patient with epidermolysis bullosa, it is difficult to cover it with a skin graft or a flap. We describe the successful use of a pedicled deep inferior epigastric perforator flap for the reconstruction of SCC associated with DEB in the groin. METHODS: A 29-year-old man diagnosed with DEB at birth sustained an ulcer increasing in the right groin for the last 7 months. Under general anesthesia, the mass lesion and lymph nodes were removed and the resulting defect was covered with a pedicled deep inferior epigastric perforator flap. RESULTS: The flap survived completely and his postoperative course was uneventful. Histopathological examination revealed a SCC in the right groin and malignant tumor cells in the removed lymph nodes as well. Additional positron emission tomogram showed a malignant lesion in the ileocecal area with regional lymph node metastasis. The patient was referred to an oncologist for chemotheraphy, but the patient refused to take it. During a 4-month follow-up period, there was no recurrence in the right groin. CONCLUSION: We suggest that perforator flaps can be considered as a reliable alternative for the reconstruction of soft tissue defects in a patient with DEB.

Clinical Experiences about Correction of Web Space Contracture and Syndactyly using V-M Plasty

PURPOSE: The loss of web space is caused by congenital syndactyly or acquired burn injury, trauma or surgery. Numerous surgical procedures have been described for restoration of the web space. Local flaps are usually preferred because of the easiness to perform and tolerable postoperative outcome. Among the various local flaps, the authors introduce V-M plasty for correction of web space contracture and syndactyly. METHOD: From March 2007 to Jun 2008, 4 patients underwent V-M plasty for correction of web space contracture and syndactyly. V-M plasty consists of 3 distinct triangular flaps. One triangular flap is designed next to the web region on the dorsal site of the hand, whereas the remaining 2 triangular flaps are placed on the volar site. The dorsal triangular flap is then placed between the volar adjacent triangular flaps. At the end of the operation, the involved fingers or toes are positioned in abduction to avoid kinking of the triangular flaps. RESULT: All the patients gained web functions with good esthetic appearance without any recurrence or complications. Mean follow-up was 8 months. CONCLUSION: V-M plasty is a safe, easy and rapid procedure to design and apply by using local tissues without the needs for a skin graft or risk of linear scarring and recurrence. The authors advise this versatile technique both in primary and recurrent cases of web space contracture and syndactyly.

Prognostic Factors of Acute Renal Failure Patients Treated with Continuous Renal Replacement Therapy / 대한신장학회지

PURPOSE: Continuous renal replacement therapy (CRRT) has been used widely for treating critically ill patients with acute renal failure (ARF). We performed this study to identify predictors of mortality in critically ill ARF patients treated with CRRT. METHODS: We analyzed the data of 128 patients who were treated with continuous veno-venous hemofiltration (CVVH) or continuous veno-venous hemodiafiltration (CVVHDF) from May, 2002 to March, 2008. We compared the clinical data of survivors with non-survivors. RESULTS: On univariate analyses of prognostic factors of patients treated with CVVHDF, APACHE II scores (p=0.004), prothrombin time (INR) (p=0.033) and the number of inotropics used (p=0.005) were significantly lower in survivors than those of non-survivors. MAP (p=0.027), diastolic BP (p=0.015) and fibrinogen level (p=0.007) were significantly higher in survivors than those of non-survivors. Multivariate analysis revealed that APACHE II scores and fibrinogen level were the independent factors for the prediction of mortality. And on univariate analyses of prognostic factors of patients treated with CVVH, APACHE II scores (p=0.002) and the number of inotropics used (p=0.006) were significantly lower in survivors than in non-survivors. MAP (p=0.03), systolic BP (p=0.02) and diastolic BP (p=0.03) were significantly higher in survivors than in non-survivors. Multivariate analysis also revealed that APACHE II scores was the only independent factor for the prediction of mortality. CONCLUSION: This study showed that the independent prognostic factor for mortality in ARF patients treated with CRRT was the APACHE II score.

Analysis of Color Difference in Facial Reconstruction Used Various Flaps

PURPOSE: Good color match is a key element in facial reconstruction for good aesthetic result. To correct the wide facial soft tissue defect were usually used the tissue expanded cheek flap, deltopectoral flap or radial forearm free flap. This study is aimed to analyse the color difference after flap surgery by using chromameter. METHODS: From August 1995 to December 2006, 30 patients who underwent flap operations were chosen randomly and evaluated color differences between flap site and adjacent skin. Reconstructive procedures included tissue expanded cheek flap(n=10), deltopectoral flap(n= 10), and radial forearm free flap(n=10). The measured sites were flap center within a radius of 1cm and four points of adjacent skin along the flap margin. The colors were quantified in a three dimensional coordinate system composed of L* (brightness), a*(redness), b*(yellowness). RESULTS: There were no significant color differences between the pedicled flaps(tissue expanded cheek flap and deltopectoral flap) and adjacent skin area. On the other hand, color values of the radial forearm free flap were statistically different from those of adjacent skin area. Total color difference(delta E) of tissue expanded cheek flap and deltopectoral flap were 7.45+/-5.78 versus 9.41+/-7.09, and that of radial forearm free flap was 11.74+/-3.85. It suggests that pedicled flaps have a potential of better color match than radial forearm free flap. CONCLUSION: Thus, better esthetic results and satisfaction is more likely to be expected in pedicled flaps as long as it could be applied comparing radial forearm free flap.

Local Flap Algorithm for the Reconstruction of Anterior Chest Wall Defects

PURPOSE: Soft tissue defect of anterior chest wall is caused by trauma, infection, tumors and irradiation. To reconstruct damaged anterior chest wall does require to consider the patient's body condition, the cause, the location, the depth and the size of deletion, the circulation of surrounding tissue and minimization of functional and cosmetic disability. In this report, we suggest the algorithm of configuration for reconstruction methods. METHODS: A retrospective study of 20 patients who underwent anterior chest wall reconstruction with pedicled musculocutaneous flap and fasciocutaneous flap was conducted. We collected the information of the patient's body condition, the cause, the size, the depth and the location of deletion, implemented flap and complication. We observed and evaluated flap compatibility, functional and cosmetic results. Patients completed survey about the extent to their satisfaction. RESULTS: Follow up period after surgery was from 6 to 26 months, survival of flap were confirmed in all of patients' case. Two cases of local necrosis, one case of wound disruption were reported, but all these were cured by the debridement and primary closure. One hematoma and one seroma formation were observed in donor site. Longer surgery time, more bleeding amount and more transfusion volume were reported in the group of musculocutenous flap. CONCLUSION: Long term follow up result showed the successful reconstruction in all patients without recurrence and with minimal donor site morbidity. In addition, the patients' satisfaction for cosmetic and functional results were scaled relatively higher. This confirmed the importance of reconstruction algorithm for the chest wall reconstruction.

Henoch-Schonlein Nephritis in Adults: Renal Outcomes and Prognostic Factors / 대한신장학회지

PURPOSE: Renal involvement of Henoch-Schonlein (HS) purpura is common, and the long-term prognosis depends on the degree of renal injury. The aim of our study was to search for prognostic factors of HS nephritis and its relationship with clinical, laboratory, and renal pathologic features. METHODS: Study population consisted of 81 patients (age > or =15 years) with HS nephritis who had been admitted to Chungnam National University Hospital from January, 1991 to February, 2008. We reviewed the clinical symptoms, laboratory data and pathologic findings of kidney of total 81 patients, and also analyzed the relationship between these and renal prognosis. RESULTS: The mean age of patients was 40.6 years and the median duration of follow-up was 16 months. Male to female ratio was 1.08. Kidney biopsies were carried out in 61 patients (75.4%). Regarding renal function, 14 (17.3%) of patients reached moderate to severe renal insufficiency, and 4 (4.9%) progressed to end-stage renal disease within 16 months (median, range 1.5-196 months) after diagnosis. Complete clinical remission was achieved in 26 patients (32.1%). The presence of gastrointestinal symptoms, relapse of purpura, hypertension, nephrotic syndrome, renal insufficiency, increased level of serum immunoglobulin A, and the magnitude of crescents and sclerotic glomeruli were significantly associated with poor renal prognosis (all p<0.05). In multivariate logistic regression analysis, initial elevated serum creatinine level and hypertension were independent prognostic factors (p=0.013, p=0.007). CONCLUSION: We concluded that the initial clinical findings including renal function and hypertension are important prognostic factors in adult HS nephritis.

Henoch-Schonlein Purpura and Peroneal Nerve Palsy after Hemorrhagic Fever with Renal Syndrome / 대한신장학회지

In the course of hemorrhagic fever with renal syndrome (HFRS), mild neurological symptoms such as headache, vertigo and nausea are common. Peripheral neuropathy in HFRS is very rare. Henoch- Sch?nlein purpura (HSP) is an immunologically medicated systemic vasculitis of small blood vessels affecting the skin, gastrointestinal tract, joints and kidneys, predominantly. Neurological complications in HSP include headache, focal cerebral deficit, coma, convulsion, subarachnoid hemorrhage and chorea. Peripheral neuropathy is also very rare. However there was no case report about HSP and peroneal nerve palsy after HFRS. With a brief review of the literature, we report a case of HSP and peroneal nerve palsy following HFRS.

Successful Treatment of Sclerosing Encapsulating Peritonitis with Tamoxifen and Prednisolone / 대한신장학회지

Sclerosing encapsulating peritonitis (SEP) is an uncommon but serious complication of long-term peritoneal dialysis (PD). Entrapment of the intestine in fibrous tissue, causing complete intestinal obstruction, is referred to as SEP. The usual clinical presentation is with partial or complete small bowel obstruction, ascites, abdominal mass, or impaired peritoneal ultrafiltration. Conservative treatment carries a poor outcome and surgery has offered variable results. Even though there is no established medical treatment, immunosuppressive drugs, steroid and tamoxifen are often used. Tamoxifen is a nonsteroidal anti-estrogenic drug commonly used in the management of breast cancer. To our knowledge, this is the first case of sclerosing encapsulating peritonitis successfully treated with tamoxifen and prednisolone in Korea. Recently, we have treated three SEP patients with tamoxifen and prednisolone. All three patients showed clinical improvement within a few months.

Reconstruction of Ischial Soft Tissue Defects using Adductor Magnus Perforator Island Flap

PURPOSE: Surgical reconstruction of an ischial soft tissue defect presents a challenging problem owing to a high rate of recurrence, especially in paraplegic patients. Although various muscle, musculocutaneous and fasciocuta- neous flaps have been used in the reconstruction of ischial soft tissue defect, it is still controversial which type of flaps are the best. We had performed a relatively durable adductor magnus perforator island flap based on the perforators originated from the first medial branch of the profunda femoris artery for coverage of ischial soft tissue defect where was not a region universally reconstructed by perforator flap. METHODS: From August 2005 to January 2008, the adductor magnus perforator island flap were used for resurfacing of the ischial soft tissue defects in a series of 6 patients(4 male and 2 female). Ages ranged from 26 to 67 years(mean, 47.5 years), and follow-up period from 13 to 26 months(mean, 16.7 months). Causes were 4 pressure ulcers, 1 cellulitis and 1 suppurative keratinous cyst. RESULTS: The sizes of these flaps ranged from 12 to 18cm in length and 7 to 9cm in width. The flaps survived in all patients. Marginal loss over the distal area of the flap by infection was noted in one patient, which was treated successfully with a subsequent split-thickness skin graft. Average thickness of the flap was 0.94cm, which was more thicker than other perforator flaps. Long term follow- up showed a good flap durability. CONCLUSION: In planning a reconstructive option of ischial soft tissue defect, the adductor magnus perforator island flap is a relatively large cutaneous flap with a durable thickness. With proper patient selection, careful vascular dissection and postoperative management, we recommend this flap as a good and suitable option for coverage of the ischial soft tissue defect.

Correction of Internal Nasal Valve Obstruction Induced by Posttraunmatic Scar Constriction: A Case Report

The borders of the internal nasal valve are defined by the caudal edge of the upper lateral cartilage supero-laterally, the cartilaginous septum medially, and the nostril floor inferiorly. It is the narrowest portion of the nasal airway and one of the primary regulator of nasal air flow. internal nasal valve collapse is a serious problem associated with prior nasal surgery, previous trauma, aging, or primary weakness of the upper lateral cartilage. We report a case of the internal nasal valve obstruction due to an uncommon mucocutaneous scarring. A 55-year-old male patient complained of headache, severe nocturnal snoring and unilateral nasal obstruction. He had a linear depressed 1.5cm in length scar on the nose dorsum, caused by a lacerated wound. The intranasal examination revealed a concentric narrowing of the left internal nasal valve area by mucocutaneous scar constriction and a left sided septal deviation, but inferior turbinate hypertrophy was not seen. After an open rhinoplasty incision, the nasal airway obstruction was relieved by scar release with the five flap Z-plasty, submucosal resection of deviated septal cartilage and unilateral spreader graft using autogenous septal cartilage. He was pleased with a significant relief of nasal obstructive symptoms. The cross- sectional size of the internal nasal valve area was maintained until postoperative 8 months. Correction of internal nasal valve obstruction must involve surgery on all the structures that make up the valve: septum, upper and lower lateral cartilage, intranasal mucosa, and the inferior turbinate.