The efficacy of cotton ball packing after endoscopic sinus surgery: A prospective, randomized, controlled trial.

OBJECTIVE: The blocking of airflow into sinonasal cavity may decrease postoperative crusting and the development of adhesions. The purpose of this study was to investigate the efficacy of cotton ball packing in patients following endoscopic sinus surgery (ESS). METHODS: Thirty nine patients with chronic rhinosinusitis requiring the same extent of ESS were included. As a part of postoperative care, the patients were instructed to perform a nasal saline irrigation and apply a nasal spray in each nostril, and then informed to put a cotton ball in a one side of nostril, and the other side was kept to be empty as a control. Patients' subjective symptoms, patients' pain while receiving sinonasal cavity debridement, time required to perform debridement, and postoperative wound healing were evaluated. RESULTS: Although cotton ball packing resulted in less discomfort for postnasal drip, rhinorrhea, headache, and facial pain than no packing, there were no statistically significant differences between the groups. The cotton ball packing was associated with significantly less pain on while performing postoperative debridement, therefore less time was needed to perform debridement. The cotton ball packing appears to improve wound healing within the sinus cavities up to 1 month postoperatively. CONCLUSION: The use of the cotton ball packing after ESS results in significantly less formation of crusts and adhesions, leading to decreasing pain and time during postoperative debridement and promoting faster wound healing.

Fibroblast growth factor receptor 3-mediated reactivation of ERK signaling promotes head and neck squamous cancer cell insensitivity to MEK inhibition.

Recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) has been a longstanding challenge for head and neck oncologists, and current treatments still have limited efficacy. ERK is aberrantly overexpressed and activated in HNSCC. Herein, we aimed to investigate the cause of the limited therapeutic effect of selumetinib, a selective inhibitor of MEK in HNSCC, as MEK/ERK reactivation inevitably occurs. We assessed the effects of combining selumetinib with fibroblast growth factor receptor 3 (FGFR3) inhibitor (PD173074) on tumor growth. Selumetinib transiently inhibited MAPK signaling and reactivated ERK signaling in HNSCC cells. Rebound in the ERK and Akt pathways in HNSCC cells was accompanied by increased FGFR3 signaling after selumetinib treatment. Feedback activation of FGFR3 was a result of autocrine secretion of the FGF2 ligand. The FGFR3 inhibitor PD173074 prevented MAPK rebound and sensitized the response of HNSCC cells to selumetinib. These results provided rational therapeutic strategies for clinical studies of this subtype of patients that show a poor prognosis with selumetinib. Our data provide a rationale for combining a MEK inhibitor with inhibitors of feedback activation of FGFR3 signaling in HNSCC cells. ERK rebound as a result of the upregulation of FGFR3 and the ligand FGF2 diminished the antitumor effects of selumetinib, which was overcome by combination treatment with the FGFR3 inhibitor.

The Effect of Postoperative Use of Teriparatide Reducing Screw Loosening in Osteoporotic Patients.

OBJECTIVE: The loosening of pedicle screws (PS) is one of the frequent problems of spinal surgery in the patients with osteoporosis. Previous studies had revealed that intermittent injection of teriparatide could reduce PS loosening by improving bone mass and quality when their patients took parathyroid hormone for a considerable duration before surgery. However, although the teriparatide is usually used after spine surgery in most clinical situations, there was no report on the efficacy of teriparatide treatment started after spine surgery. The purpose of this retrospective study was to examine the efficacy of teriparatide treatment started immediately after lumbar spinal surgery to prevent pedicle screw loosening in patients with osteoporosis. METHODS: We included 84 patients with osteoporosis and degenerative lumbar disease who underwent transforaminal interbody fusion and PS fixation and received parathyroid hormone or bisphosphonate (BP) postoperatively. They were divided into teriparatide group (daily injection of 20 µg of teriparatide for 6 months, 33 patients, 172 screws) and BP group (weekly oral administration of 35 mg of risedronate, 51 patients, 262 screws). Both groups received calcium (500 mg/day) and cholecalciferol (1000 IU/day) together. The screw loosening was evaluated with simple radiographic exams at 6 and 12 months after the surgery. We counted the number of patients with PS loosening and the number of loosened PS, and compared them between the two groups. Clinical outcomes were evaluated using visual analog scale (VAS) and Oswestry disability index (ODI) preoperatively, and at 12 months after surgery. RESULTS: There was no significant difference in the age, sex, diabetes, smoking, bone mineral density, body mass index, and the number of fusion levels between the two groups. The number of PS loosening within 6 months after surgery did not show a significant difference between the teriparatide group (6.9%, 12/172) and the BP group (6.8%, 18/272). However, during 6-12 months after surgery, it was significantly lower in the teriparatide group (2.3%, 4/172) than the BP group (9.2%, 24/272) (p<0.05). There was no significant difference in the number of patients showing PS loosening between the teriparatide and BP groups. The teriparatide group showed a significantly higher degree of improvement of the bone mineral density (T-score) than that of BP group (p<0.05). There was no significant difference in the pre- and post-operative VAS and ODI between the groups. CONCLUSION: Our data suggest that the teriparatide treatment starting immediately after lumbar spinal fusion surgery could reduce PS loosening compared to BP.

Does drug-induced sleep endoscopy predict surgical success of limited palatal muscle resection in patients with obstructive sleep apnea?

OBJECTIVE: The aims of this study were to determine the associated factors affecting the success rate of limited palatal muscle resection (LPMR), and to investigate whether drug-induced sleep endoscopy (DISE) could predict the therapeutic response to LPMR in patients with obstructive sleep apnea obstructive sleep apnea (OSA). METHODS: Twenty-one consecutive OSA patients underwent LPMR were enrolled. All patients received routine ENT examination, preoperative DISE, and polysomnography (PSG). Clinical, polysomnographic, cephalometric variables, and DISE findings were evaluated. The measurements were related to the success or failure of LPMR based on the results of preoperative and postoperative PSG. RESULTS: The overall success rate of LPMR was 66.6%. Postoperative AHI and minimal oxygen saturation were significantly decreased after LPMR (p<0.001). Comparison between success and failure groups revealed no significant differences in BMI, Friedman stage, preoperative AHI, minimal oxygen saturation, and all cephalometric parameters. However, the success of LPMR was significantly correlated with site, degree, and configuration of obstruction in DISE. In the velopharynx, complete obstruction (p=0.006) with anterolateral or concentric pattern (p=0.044) had significantly better success rate than partial obstruction with lateral pattern. CONCLUSION: DISE was only predictive method for identifying the success in OSA patients undergoing LPMR. Patients with anteroposterior or concentric total obstruction in the velopharynx might be suitable candidate for LPMR.

A clinical prediction score to determine surgical drainage of deep neck infection: A retrospective case-control study.

BACKGROUND: The objective of this retrospective study was to identify predictors of an abscess guaranteed to be surgically drained successfully in patients with deep neck infection (DNI). MATERIALS AND METHODS: We divided 97 consecutive patients with DNI into a drained group and a non-drained group. We then developed a clinical prediction score and validated it in 32 further patients. RESULTS: Significant predictors of successful surgical drainage (i.e., positive for pus) were rim enhancement on computed tomography, C-reactive protein, erythrocyte sedimentation rate, and the neutrophil to lymphocyte ratio. The estimated cut-off values (excluding rim enhancement, which is a yes/no parameter) were 41.25, 56.5, and 8.02, respectively, and the clinical prediction score for each of the four other factors was determined to be 2, 2, 3, and 3 points, respectively. The cut-off score for the sum of these points was 6.5 and the scoring system had an accuracy of 87.5% in the validation group. CONCLUSION: Our clinical prediction scoring system can predict whether drainage is successful in patients with DNI.

Korean survey data reveals an association of chronic laryngitis with tinnitus in men.

The association between chronic laryngitis and tinnitus is not a well-studied topic, unlike the association of these two conditions with many other disorders. Cross-sectional data of 11,347 adults (males: 4,934; females: 6,413), who completed the Korea National Health and Nutrition Examination Survey (KNHANES) from 2010 to 2012 were used to investigate this association. Lifestyle patterns, including smoking and alcohol habits, regular exercise, physical and mental health status, socioeconomic status, nutritional status, and other chronic diseases, were analyzed. Chronic laryngitis and tinnitus were diagnosed by field survey teams, which included otolaryngologists, who conducted chronic disease surveillance using a health status interview, a nutritional status questionnaire, and a physical examination. Chronic laryngitis was significantly associated with age, education beyond high school, depressed mood, voice change, metabolic syndrome, and tinnitus in men. In women, chronic laryngitis was associated with body mass index and diabetes mellitus. Chronic laryngitis in men was significantly associated with tinnitus (odds ratio 1.671, [95% confidence interval: 1.167-2.393]) after adjusting for age, body mass index, smoking status, alcohol intake, regular exercise, metabolic syndrome, education beyond high school, and depressed mood. Additionally, the prevalence of chronic laryngitis increased with increasing severity of tinnitus in men alone (P = 0.002). The study revealed a significant association between chronic laryngitis and tinnitus.

Acquired resistance to BRAF inhibition induces epithelial-to-mesenchymal transition in BRAF (V600E) mutant thyroid cancer by c-Met-mediated AKT activation.

Previously, the authors have identified that c-Met mediates reactivation of the PI3K/AKT pathway following BRAF inhibitor treatment in BRAF (V600E) mutant anaplastic thyroid cancer, thereby contributing to the acquired drug resistance. Therefore dual inhibition of BRAF and c-Met led to sustained treatment response, thereby maximizing the specific anti-tumor effect of targeted therapy. The present study goes one step further and aims to investigate the effect of acquired resistance of BRAF inhibitor on epithelial-to-mesenchymal transition (EMT) in BRAF mutant thyroid cancer cells and the effect of dual inhibition from combinatorial therapy. Two thyroid cancer cell lines, 8505C and BCPAP were selected and treated with BRAF inhibitor, PLX4032 and its effect on EMT were examined and compared. Further investigation was carried out in orthotopic xenograft mouse models. Unlike BCPAP cells, the BRAF inhibitor resistant 8505C cells showed increased expressions of EMT related markers such as vimentin, ß-catenin, and CD44. The combinatorial treatment of PLX4032 and PHA665752, a c-Met inhibitor reversed EMT. Similar results were confirmed in vivo. c-Met-mediated reactivation of the PI3K/AKT pathway contributes to the drug resistance to PLX4032 in BRAF (V600E) mutant anaplastic thyroid cancer cells and further promotes tumor cell migration and invasion by upregulated EMT mechanism. Dual inhibition of BRAF and c-Met leads to reversal of EMT, suggesting a maximal therapeutic response.

The Efficacy of Fibroblast Growth Factor for the Treatment of Chronic Vocal Fold Scarring: From Animal Model to Clinical Application.

OBJECTIVES: This study assessed the regenerative efficacy of basic fibroblast growth factor (FGF) in a rabbit model of chronic vocal fold scarring and then confirmed its utility and safety in a prospective trial of patients with this condition. METHODS: FGF was injected three times, at 1-week intervals, into a chronic vocal fold scar created in a rabbit model. After 1 month, mRNA level of procollagen I, hyaluronic acid synthetase 2 (HAS 2), and matrix metalloproteinase 2 (MMP 2) were analyzed by real-time polymerase chain reaction. The relative densities of hyaluronic acid (HA) and collagen were examined 3 months post-injection. From April 2012 to September 2014, a prospective clinical trial was conducted at a tertiary hospital in Korea. FGF was injected into the mild vocal fold scar of 17 consecutive patients with a small glottic gap. The patients underwent perceptual, stroboscopic, acoustic aerodynamic test, and Voice Handicap Index (VHI) survey prior to and 3, 6, and 12 months after FGF injection. RESULTS: FGF injection of the vocal fold scar decreased the density of collagen and increased mRNA level of HAS 2 and MMP 2 expression significantly compared to the control group injected with phosphate buffered solution in a rabbit model (P<0.05). In the clinical trial, significant improvements in the majority of the subjective and objective voice parameters were registered 3 months after FGF injection and were maintained at 12 months. Complications associated with the FGF injections, such as granuloma, were not observed during the follow-up period. CONCLUSION: Based on the animal model and the prospective clinical trial, vocal fold injections of FGF in patients with mild chronic vocal fold scarring can significantly improve voice quality for as long as 1 year and without side effects. Our results recommend the use of FGF vocal fold injection as an alternative treatment modality for mild chronic vocal fold scarring.

Septochoanal Polyp with Metaplastic Ossification Mimicking Sinonasal Tumor: A Case Report.

Choanal polyps are a form of nasal polyps that grow toward the choana with a single stalk. Septochoanal polyp is a rare entity that originates from the mucosa of the nasal septum with choanal extension. The most common site of its origin is mainly the superior aspect of the posterior portion of the nasal septum. However, metaplastic ossification is a rare event in nasal polyp and to the best of our knowledge, septochoanal polyp with metaplastic ossification has not been reported in the literature. Herein, we report a case of huge septochoanal polyp with metaplastic ossification obstructing both the nasal cavity and nasopharynx, which was successfully removed via transnasal endoscopic approach.

Giant fibrovascular polyp on aryepiglottic fold.

Polyps are common lesions in pharynx and larynx. A 46-year-old woman was transferred to our department because of the huge laryngeal mass, which was incidentally detected during routine health screening. On laryngoscopic exam, both vocal folds were not visualized due to the mass but she had no symptom such as hoarseness, dysphagia, and dyspnea. Awake intubation was safely performed using flexible bronchoscope without tracheostomy. A 4-cm sized mass on the left aryepiglottic fold was removed with trans-oral approach and discharged without complication. The pathologic diagnosis was reported as 'fibrovascular polyp'. Herein, we describe a unique case of giant fibrovascular polyp on aryepiglottic fold, which is the first report in the English literature.

Anti-Proliferative and Apoptotic Activities of Müllerian Inhibiting Substance Combined with Calcitriol in Ovarian Cancer Cell Lines.

PURPOSE: This study aimed to investigate whether Müllerian inhibiting substance (MIS) in combination with calcitriol modulates proliferation and apoptosis of human ovarian cancer (OCa) cell lines (SKOV3, OVCAR3, and OVCA433) and identify the signaling pathway by which MIS mediates apoptosis. MATERIALS AND METHODS: OCa cell lines were treated with MIS in the absence or presence of calcitriol. Cell viability and proliferation were evaluated using the Cell Counting Kit-8 assay and apoptosis was evaluated by DNA fragmentation assay. Western blot and enzyme-linked immunosorbent assay were used to determine the signaling pathway. RESULTS: The cells showed specific staining for the MIS type II receptor. Treatment of OCa cells with MIS and calcitriol led to dose- and time-dependent inhibition of cell growth and survival. The combination treatment significantly suppressed cell growth, down-regulated the expression of B-cell lymphoma 2 (Bcl-2), and up-regulated the expressions of Bcl-2 associated X protein, caspase-3, and caspase-9 through the extracellular signal-regulated kinase signaling pathway. CONCLUSION: These results, coupled with a much-needed decrease in the toxic side effects of currently employed therapeutic agents, provide a strong rationale for testing the therapeutic potential of MIS, alone or in combination with calcitriol, in the treatment of OCa.

Hypoxia Induces Epithelial-Mesenchymal Transition in Follicular Thyroid Cancer: Involvement of Regulation of Twist by Hypoxia Inducible Factor-1α.

PURPOSE: Although follicular thyroid cancer (FTC) has a relatively fair prognosis, distant metastasis sometimes results in poor prognosis and survival. There is little understanding of the mechanisms contributing to the aggressiveness potential of thyroid cancer. We showed that hypoxia inducible factor-1α (HIF-1α) induced aggressiveness in FTC cells and identified the underlying mechanism of the HIF-1α-induced invasive characteristics. MATERIALS AND METHODS: Cells were cultured under controlled hypoxic environments (1% O2) or normoxic conditions. The effect of hypoxia on HIF-1α, and epithelial-to-mesenchymal transition (EMT) related markers were evaluated by quantitative real-time PCR, Western blot analysis and immunocytochemistry. Invasion and wound healing assay were conducted to identify functional character of EMT. The involvement of HIF-1α and Twist in EMT were studied using gene overexpression or silencing. After orthotopic nude mouse model was established using the cells transfected with lentiviral shHIF-1α, tissue analysis was done. RESULTS: Hypoxia induces HIF-1α expression and EMT, including typical morphologic changes, cadherin shift, and increased vimentin expression. We showed that overexpression of HIF-1α via transfection resulted in the aforementioned changes without hypoxia, and repression of HIF-1α with RNA interference suppressed hypoxia-induced HIF-1α and EMT. Furthermore, we also observed that Twist expression was regulated by HIF-1α. These were confirmed in the orthotopic FTC model. CONCLUSION: Hypoxia induced HIF-1α, which in turn induced EMT, resulting in the increased capacity for invasion and migration of cells via regulation of the Twist signal pathway in FTC cells. These findings provide insight into a possible therapeutic strategy to prevent invasive and metastatic FTC.

Common Pesticides Used in Suicide Attempts Following the 2012 Paraquat Ban in Korea.

To determine the change in pesticides used during suicide attempts after the 2012 paraquat (PQ) ban, we evaluated the annual number of suicide attempts by pesticide ingestion between 2011 and 2014. We extracted demographic, clinical outcome, and pesticide class data from the medical records of 1,331 patients that attempted suicide by pesticide ingestion. Pesticides were sorted into 5 groups: herbicides, insecticides, fungicides, other pesticides, and combined pesticides. Each group was subdivided into various classes based on publications by the respective Resistance Action Committees. The chi-square test for trends was used to compare the annual incidence of categorical variables. The total number of suicide attempts decreased each year, from 399 in 2011 to 245 in 2014. Simultaneously, PQ ingestion decreased from 253 patients in 2011 to 60 in 2014. The proportion of PQ to pesticides also decreased from 63.4% in 2011 to 24.5% in 2014. Furthermore, the rate of decrease in the proportion of PQ to all herbicide categories increased by calendar year. In conclusion, there is a significant trend in increased annual number of suicides and proportion of suicides using glyphosates and glufosinates versus total herbicides. However, the number of suicide attempts using glyphosate and glufosinate is lower than that using PQ. The ratio of persons completing suicide to those attempting suicide after pesticide ingestion has decreased every year after the PQ ban.

The Role of Transnasal Esophagoscopy in ENT Office: A Prospective, Multicenter Study in Korea.

OBJECTIVES: The purpose of study was to report the current role of transnasal esophagoscopy (TNE) in Korea. METHODS: One hundred thirty-seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to February 2009 were prospectively analyzed. Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1. RESULTS: Fifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). Forty-two patients (41.1%) were found to have pathology (esophagitis, n=41; esophageal diverticulum, n=1) during the screening examination for LPRD. There were no significant complications in any of the patients. CONCLUSION: TNE is a high-yield diagnostic and therapeutic modality available to otolaryngologists for use on awake patients in the office setting.

A cervical vagal schwannoma mimicking a parathyroid cyst.

Cervical vagal schwannomas with cystic degeneration changes are extremely rare. These tumors are typically benign and slow growing. A 44-year-old woman underwent complete resection of a tumor measuring 4×3.5 cm in the right neck using the endoscopic approach, instead of the conventional transcervical approach. We applied the new scarless neck surgery technique with an endoscopic unilateral axillo-breast approach. The tumor originated from the right vagus nerve, and was confirmed to be a vagal schwannoma pathologically. The patient has been followed up for 18 months postoperatively with no evidence of tumor recurrence or neurological deficit. We report an extremely rare vagal schwannoma with cystic degeneration that was removed by an endoscopic approach, along with a review of the relevant literature.

Coexistence of a carotid body tumor and thyroglossal duct carcinoma with cervical lymph node metastasis.

Thyroglossal duct carcinoma is uncommon, occurring in approximately 1% of all thyroglossal duct remnants. This rare neoplasm is characterized by relatively nonaggressive behavior with infrequent lymph nodal spread. Another rare neoplasm of the head and neck region is a carotid body tumor. A 78-year-old woman with a 3-year history of midline and bilateral neck masses was referred to us. Fine needle aspiration biopsies and a computed tomography scan suggested the diagnosis of thyroglossal duct carcinoma with cervical lymph node metastasis. Interestingly, the left-side neck mass was found to be splaying the carotid bifurcation, on computed tomography imaging. Carotid arteriography demonstrated a highly vascular mass in the bifurcation of the carotid artery that was compressing the internal and external carotid arteries. To our knowledge, this is the first reported instance of a thyroglossal duct carcinoma with neck metastasis accompanied by a carotid body tumor. In addition, the carotid body tumor in this case mimicked neck metastasis from the thyroglossal duct carcinoma.

A comparison of the clinical duration and recovery characteristics of cisatracurium after priming using rocuronium or cisatracurium: preliminary study.

BACKGROUND: The priming technique can speed up the onset of cisatracurium during intubation. However, there have been no reports on the effect of the priming technique on duration or recovery profile of cisatracurium. Therefore, we attempted to determine whether or not a priming technique with rocuronium or cisatracurium can affect clinical duration or recovery profiles of cisatracurium. METHODS: A total of 36 patients, ASA I and II, who were scheduled to undergo elective surgery, were enrolled. The patients were randomized into three groups and administered different drugs for the priming technique. Patients in group 1 received normal saline (control group). Patients in group 2 received rocuronium (0.06 mg/kg), and those in group 3 received cisatracurium (0.01 mg/kg) as a priming agent. Three minutes after injection of drugs, intubation doses of cisatracurium were administered (Group 1, 0.15 mg/kg; Groups 2 and 3, 0.14 mg/kg). Anesthesia was induced and maintained with propofol and remifentanil. Onset time, clinical duration, recovery index, recovery time, and total recovery time were measured by train of four monitoring. RESULTS: Onset time in the group 2 was significantly shorter than that of group 1 or 3 (P < 0.05). However, no significant differences in clinical duration, recovery index, recovery time, and total recovery time were observed among the three groups. CONCLUSIONS: Priming with rocuronium for 3 minutes resulted in significantly accelerated onset of cisatracurium. However, it did not affect the clinical duration and recovery profiles of cisatracurium.

Second primary mucosal malignant melanoma in hypopharynx.

Primary mucosal melanomas of the head and neck are rare. In addition, second primary mucosal melanoma following primary cutaneous malignant melanomas is very rare. We report a second primary mucosal melanoma. A 76-year-old woman, who had a previously cutaneous malignant melanoma of the left foot, visited with a complaint of a foreign body sensation of the throat. Endoscopy revealed a black mass at the left piriform sinus of the hypopharynx. After wide surgical excision of the lesion and reconstruction with a radial forearm free flap, the histopathology was confirmed to be a second primary mucosal malignant melanoma of the hypopharynx. Five months postoperatively, masses were palpated in the neck, and metastasis was diagnosed. The patient was treated with adjuvant chemotherapy and radiotherapy. Eight months postoperatively, computed tomography scans showed other metastatic masses in the liver, spleen, both adrenal glands, soft tissues of the abdominal wall, and both lungs. After that, the patient died 9 months postoperatively. We report a rare case of second primary mucosal malignant melanoma of the hypopharynx. Although rare, this case shows that a detailed examination of the hypopharynx and the head and neck should be a part of the follow-up examination in all cutaneous malignant melanoma patients.