A Case of Nasal Desmoid Tumor / 대한이비인후과학회지

Desmoid fibromatosis is a very slowly growing benign fibroblast tumor. Locally aggressive and non-metastasizing, it is a well-differentiated, unencapsulated monoclonal myofibroblastic proliferation that has a tendency for local invasion and recurrence. About 15% of all desmoidtype fibromatosis develops within the head and neck. The majority of head and neck desmoid tumor is located in the neck, but less frequently in the face, scalp, oral cavity, mandible, paranasal sinuses, orbit, ear and other structures. We report a very rare case in a 55-year-old female of a desmoid fibromatosis arising from the lateral nasal wall of anterior portion of uncinated process. We discuss the clinicopathologic features and successful treatment of nasal desmoid tumor with a literature review.

Nasal Nitric Oxide in the Upper Airway Inflammatory Diseases

Exhaled nitric oxide (eNO) from the lower respiratory tract is used commonly in diagnosis and treatment monitoring of asthma patients. However, nasal nitric oxide (nNO) has not been widely used in patients with upper airway inflammatory diseases due to its lack of standardized measurement methods. Nasal nitric oxide is produced mainly by the paranasal sinus mucosa and partially by the nasal mucosa and increases with inflammation. Nasal nitric oxide not only locally supports the defensive mechanism of the upper respiratory tract, but also remotely controls pulmonary function by acting as an aerocrine. Nasal NO can be affected by various physiologic and pathologic factors of the upper respiratory tract. This article will review the origin of nNO, its function, various measurement methods, and difference in presentation among upper respiratory tract inflammatory diseases such as allergic rhinitis, upper respiratory tract infection, nasal polyp, rhinosinusitis, primary ciliary dyskinesia, cystic fibrosis, Young’s syndrome, diffuse panbronchiolitis, empty nose syndrome, and obstructive sleep apnea. Future studies should identify the mechanism of action of nNO in various upper respiratory tract inflammatory diseases and obtain highly reproducible normal values of nNO based on a standardized measurement method with a deeper understanding of factors affecting nNO. Then, nNO will be useful for more rapid and simpler diagnosis of various upper respiratory tract diseases and for monitoring their treatment.

Nasal Nitric Oxide in the Upper Airway Inflammatory Diseases

Exhaled nitric oxide (eNO) from the lower respiratory tract is used commonly in diagnosis and treatment monitoring of asthma patients. However, nasal nitric oxide (nNO) has not been widely used in patients with upper airway inflammatory diseases due to its lack of standardized measurement methods. Nasal nitric oxide is produced mainly by the paranasal sinus mucosa and partially by the nasal mucosa and increases with inflammation. Nasal nitric oxide not only locally supports the defensive mechanism of the upper respiratory tract, but also remotely controls pulmonary function by acting as an aerocrine. Nasal NO can be affected by various physiologic and pathologic factors of the upper respiratory tract. This article will review the origin of nNO, its function, various measurement methods, and difference in presentation among upper respiratory tract inflammatory diseases such as allergic rhinitis, upper respiratory tract infection, nasal polyp, rhinosinusitis, primary ciliary dyskinesia, cystic fibrosis, Young’s syndrome, diffuse panbronchiolitis, empty nose syndrome, and obstructive sleep apnea. Future studies should identify the mechanism of action of nNO in various upper respiratory tract inflammatory diseases and obtain highly reproducible normal values of nNO based on a standardized measurement method with a deeper understanding of factors affecting nNO. Then, nNO will be useful for more rapid and simpler diagnosis of various upper respiratory tract diseases and for monitoring their treatment.

Clinical Characteristics of Cervical Toxoplasma Lymphadenitis / 대한이비인후과학회지

Background and Objectives@#Toxoplasmosis is a disease caused by an intracellular parasite, Toxoplasma gondii. There has been only a few studies done on cervical toxoplasma lymphadenitis, and this study was performed to evaluate its clinical characteristics and outcomes.Subjects and Method We retrospectively reviewed the patients diagnosed with cervical toxoplasma lymphadenitis from January 2010 to December 2019. We investigated clinical pathologic findings, treatment and clinical outcomes. @*Results@#Enrolled in the study were 21 patients who were confirmed with typical pathologic findings in an excisional biopsy (16/21) and core needle biopsy (5/21). Nine patients were male and 12 patients were female, with the mean age of 46.1±13.59 (19-70). All patients complained of neck masses and 5 (23.8%) patients showed pain or tenderness. Only one (4.8%) patient had mild fever. Fine needle aspiration cytology was performed in 5 patients, with no resulting pathognomonic outcomes in any one of the patients. CT scan was performed in 15 patients, with 8 (53.3%) patients showing multiple nodal enlargements but 7 (46.6%) patients showing a single enlarged lymph node. The most frequently involved location was level I (53.3%), followed by level II (46.6%), level V (46.6%), level III (40.0%), and level IV (20.0%). The serologic test for toxoplasma revealed positive IgG (100%) and IgM (85.7%). Treatments were excision only (61.9%) and excision with pharmacologic treatment using sulfonamide or pyrimethamine (38.1%). There was no case of recurrence after treatment. @*Conclusion@#Cervical toxoplasma lymphadenitis can be diagnosed by biopsy but needle aspiration has little role. It shows favorable clinical outcomes after treatment.

Local Allergic Inflammation in Chronic Rhinosinusitis With Nasal Polyps Could Influence on Disease Severity and Olfaction

Background and Objectives@#Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial disease resulting from inflammation of the nasal cavity and paranasal sinuses. Systemic allergic inflammation is an important cause of CRSwNP; however, the effect of local allergic inflammation is unclear. This study was designed to investigate the effect of local allergic inflammation in CRSwNP. @*Materials and Methods@#The study included 11 patients with CRSwNP and 18 control subjects. Olfactory function was measured with the Korean Version of Sniffin’s stick test. Nasal lavage fluids (NLFs) were collected from all subjects and analyzed for total IgE, eosinophilic cationic protein (ECP), and cytokines (tumor necrosis factor [TNF]-α, interleukin [IL]-4, IL-10, IL-17A, interferon-γ). Flow cytometry was used to measure various inflammatory cells in the NAL fluids. @*Results@#On analysis of flow cytometry and enzyme-linked immunosorbent assay, we found that CRSwNP patients had significantly increased eosinophil (%) and ECP levels in NLFs. In addition, there was significant local-systemic correlation between ECP level in NLFs and blood eosinophils (%) (r=0.391); however, there was no significant association between eosinophils (%) in NLFs and blood eosinophils. Moreover, in CRSwNP patients, the severity of disease was related with blood eosinophil (%), eosinophil (%), and ECP levels in NLFs, whereas olfactory function was associated with blood eosinophil (%) and ECP levels in NLFs. @*Conclusion@#CRSwNP is a disease with high allergic inflammation that has negative impacts on the severity of disease and olfactory function. Therefore, we suggest that control of local allergic inflammation will be helpful to treat CRSwNP patients.

Revision of threshold levels for evoking pollinosis to oak, pine, Japanese hop, and ragweed in the metropolitan area Seoul, Korea

Purpose@#The threshold levels for symptom development of pollinosis vary among studies and countries. This study aimed to determine currently used threshold levels for it. @*Methods@#Oak, pine, Japanese hop, and ragweed pollen samples were collected daily for 8 years from the Seoul and Guri areas. A total of 792 subjects with allergy to these pollens were recruited. The symptom index (SI) was assessed through telephone interviews and allergy questionnaires, and data were analyzed using decision tree. @*Results@#The risk index for oak pollen allergy was “mild” when the pollen count was 0–2 grains/m3 , “moderate” when it was 3–11 grains/m3 , “severe” when it was 12–28 grains/m3 , and “dangerous” when it was ≥ 29 grains/m3 . The risk level for pine pollen allergy was “mild” when the pollen count was 0–4 grains/m 3 , “moderate” when it was 5–42 grains/m3 , “severe” when it was 43–66 grains/m3 , and “dangerous” when it was ≥ 67 grains/m3 . For Japanese hop pollen allergy, the risk level was “mild” when the pollen count was 0–8 grains/m3 , “moderate” when it was 9–10 grains/m3 , “severe” when it was 11–19 grains/m3 , and “dangerous” when it was ≥ 20 grains/m3 . Finally, for ragweed, the risk level was “mild” when the pollen count was 0–1 grains/m3 , “moderate” when it was 2–6 grains/m3 , “severe” when it was 7–33 grains/m3 , and “dangerous” when it was ≥ 34 grains/m3 . @*Conclusions@#Revising the threshold levels for the risk index for pollen allergies may be useful for developing pollen prediction models for patients with pollen allergies in Korea.

Efficacy of Transcartilaginous Electrodes for Intraoperative Neural Monitoring During Thyroid Surgery

Objectives@#. This study was conducted evaluate the efficacy of electromyography (EMG) using transcartilaginous (TC) electrodes through the thyroid cartilage and perichondrium. @*Methods@#. We prospectively collected EMG data from intraoperative neuromonitoring (IONM) of 54 nerves at risk in 38 patients during thyroidectomy. We followed standardized IONM procedures in all operations. EMG signals from both endotracheal tube (ET) electrodes and TC needle electrodes were recorded simultaneously. We compared the characteristics of the EMG signals and the efficacy of both methods. @*Results@#. Significantly higher mean EMG amplitudes were recorded by TC electrodes than by ET electrodes in all four-step procedures (V1-R1-R2-V2, P<0.001). Loss of signal (LOS) occurred in five patients in ET electrodes, but in only two patients in TC electrodes. Postoperative laryngoscopy revealed recurrent laryngeal nerve palsy in the two patients who showed LOS from both the ET and TC electrodes, and vocal cord movement was intact in the other three patients. Therefore, the positive predictive values of LOS in ET and TC electrodes were 40% and 100%, respectively. @*Conclusion@#. EMG recording using TC needle electrodes is feasible and effective, making it a good alternative technique for IONM.

A Case of Large Cell Neuroendocrine Carcinoma of the Maxillary Sinus / 대한두경부종양학회지

Large cell neuroendocrine carcinoma is a rare epithelial neuroendocrine malignancy and is preferentially located in gastrointestinal tract and pancreas. Cases of large cell neuroendocrine carcinoma have been reported in many other locations, including the thymus, gallbladder, prostate, larynx, salivary glands, nasopharynx, tonsil and mastoid. However, primary sinonasal large cell neuroendocrine carcinoma never have been reported in Korea. We experienced a case of primary large cell neuroendocrine carcinoma arising from left maxillary sinus recently. A 82-year-old male patient presented with nasal obstruction and epistaxis. The biopsy revealed large cell neuroendocrine carcinoma with poor differentiation. After a general evaluation, the patient was staged as cT3N0M0. The patient was treated by combined radiotherapy and chemotherapy. We report this rare case with literature review.

Long-Term Effects of Adenotonsillectomy on Growth and Symptoms in Childhood / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: This study was performed to evaluate the long-term effect of adenotonsillectomy on childhood growth by examining preoperative growth status and presenting symptoms. SUBJECTS AND METHOD: One hundred and four patients who underwent adenotonsillectomy from January to December 2009 were enrolled in this study. Clinical data were collected from medical record reviews and through the administered questionnaire. We investigated symptoms and growth changes during 5 years following the surgery. RESULTS: The mean age of patients was 6.0±1.94 years (range, 3–10), with the male to female ratio of 62:42. Pre-operative symptoms were significantly improved after the surgery. The mean pre-operative height and weight percentiles were 53.6±27.4 and 59.6±29.2 at initial evaluation, and 67.1±26.4 and 59.6±28.6 at 5 years post adenotonsillectomy (p < 0.001, p=0.989), respectively. An increase in height percentile was more prominent in patients whose pre-operative height percentile was less than 50 compared to those with a percentile of 50 or more (p < 0.001). Weight percentile was significantly increased in those with the pre-operative weight percentile of less than 50 and decreased in patients with a percentile of 50 or more. CONCLUSION: Adenotonsillectomy has a positive effect on height growth in children with adenotonsillar hypertrophy, especially in patients whose height percentile is less than 50. Weight gain also can be expected in preoperative low-weight children.

A Case of Periorbital Necrotizing Fasciitis Occurred in Patient with Fungal Sinusitis / 대한이비인후과학회지

Orbital complications due to sinusitis usually occur in children and spread from the ethmoid or frontal sinusitis. Periorbital necrotizing fasciitis, which is an aggressive infection characterized by extensive necrosis and gas formation in the fascia and subcutaneous tissue, is uncommon as an orbital complication due to sinusitis. Because most of orbital complications of the fungal sinusitis occur from invasive fungal infection in immunocompromised patients, orbital complications due to non-invasive maxillary fungal ball in healthy patients are extremely rare, especially if the complication is periorbital necrotizing fasciitis. We report a case of periorbital necrotizing fasciitis that occurred in a healthy 44-year-old male patient with non-invasive fungal sinusitis, which was treated with a combination of intravenous antibiotics and endoscopic sinus surgery and ophthalmologic surgical treatment.

A Case of Periorbital Necrotizing Fasciitis Occurred in Patient with Fungal Sinusitis / 대한이비인후과학회지

Orbital complications due to sinusitis usually occur in children and spread from the ethmoid or frontal sinusitis. Periorbital necrotizing fasciitis, which is an aggressive infection characterized by extensive necrosis and gas formation in the fascia and subcutaneous tissue, is uncommon as an orbital complication due to sinusitis. Because most of orbital complications of the fungal sinusitis occur from invasive fungal infection in immunocompromised patients, orbital complications due to non-invasive maxillary fungal ball in healthy patients are extremely rare, especially if the complication is periorbital necrotizing fasciitis. We report a case of periorbital necrotizing fasciitis that occurred in a healthy 44-year-old male patient with non-invasive fungal sinusitis, which was treated with a combination of intravenous antibiotics and endoscopic sinus surgery and ophthalmologic surgical treatment.

Postoperative Hypoparathyroidism and the Viability of the Parathyroid Glands During Thyroidectomy

OBJECTIVES: To prevent hypoparathyroidism after thyroidectomy, preservation of the parathyroid glands and their vascularity are essential. The aim of this study was to determine the association between postoperative parathyroid function and the viability of the parathyroid glands during thyroidectomy. METHODS: We prospectively analyzed 111 patients who underwent total thyroidectomy and in whom all 4 parathyroid glands were preserved in situ during the operation. The surgeons scored the viability of each parathyroid gland from 0 (normal) to 3 (severely compromised viability) based on its gross appearance and vascularity intraoperatively. The index of parathyroid viability score (IPVS) was defined as the sum of the viability scores of the 4 parathyroid glands. We evaluated the relationship between postoperative parathyroid function and IPVS. RESULTS: Transient hypoparathyroidism occurred in 25 patients (22.5%), and permanent hypoparathyroidism in 4 patients (3.6%). The IPVS were significantly different in the three groups: 2.87±1.46 in the normal group, 3.68±1.41 in the transient hypoparathyroidism group and 7.50±1.00 in the permanent hypoparathyroidism group. The rates of transient hypoparathyroidism were 13.6% in patients with IPVS 0–2, 23.8% in patients with IPVS 3–4, and 42.9% in patients with IPVS 5–6. All the patients with IPVS of 7 or more had permanent hypoparathyroidism. CONCLUSION: IPVS is correlated with the incidence of hypoparathyroidism. It could be a good quantitative indicator of the probability of hypoparathyroidism after thyroidectomy.

The Effectiveness of Budesonide Nasal Irrigation After Endoscopic Sinus Surgery in Chronic Rhinosinusitis With Asthma

OBJECTIVES: Budesonide nasal irrigation was introduced recently for postoperative management of patients with chronic rhinosinusitis. The safety and therapeutic effectiveness of this procedure is becoming accepted by many physicians. The objective of this study was to evaluate the efficacy of postoperative steroid irrigation in patients with chronic rhinosinusitis and asthma. METHODS: This prospective study involved 12 chronic rhinosinusitis patients with nasal polyps and asthma who received oral steroid treatment for recurring or worsening disease. The 22-item Sinonasal Outcomes Test (SNOT-22) and Lund-Kennedy endoscopy scores were checked before nasal budesonide irrigation, and 1, 2, 4, and 6 months after irrigation. We also calculated the total amount of oral steroids and inhaled steroids in the 6 months before irrigation and the 6 months after it. RESULTS: The mean SNOT-22 score improved from 30.8±14.4 before irrigation to 14.2±8.7 after 6 months of irrigation (P=0.030). The endoscopy score also improved from 7.4±4.7 before irrigation to 2.2±2.7 after 6 months (P<0.001). The total amount of oral steroid was decreased from 397.8±97.6 mg over the 6 months before irrigation to 72.7±99.7 mg over the 6 months after irrigation (P<0.001). CONCLUSION: Nasal irrigation with budesonide is an effective postoperative treatment for chronic rhinosinusitis with asthma, which recurs frequently, reducing the oral steroid intake.

A Case of Immunoglobulin G4-Related Sclerosing Disease not Responded to Steroid in Nasal Cavity

IgG4-related sclerosing disease was first discovered when researching autoimmune pancreatitis. It is an autoimmune disease that causes fibrosis on the pancreas, bile duct, gall bladder, salivary glands, and lungs. It is rarely reported in the nasal cavity. The diagnosis of IgG4-related sclerosing disease is based on biopsy findings demonstrating the characteristic histopathologic findings and immunohistochemical staining. IgG4-related sclerosing disease shows good response to high-dose steroid therapy. However, some patients do not respond to this treatment. Azathioprine or rituximab can be helpful in such case. We report our experience with IgG4-related sclerosing disease treated with azathioprine for 2 years, along with a related literature review.

A Case of Multiple Myeloma in Bilateral Paranasal Sinuses with Loss of Vision / 대한이비인후과학회지

Plasmacytoma refers to malignant plasma cell tumor, which consists of abnormal proliferation of plasma cells. It can be classified into several types, multiple myeloma, solitary medullary plasmacytoma and extramedullary plasmacytoma according to clinical and histological aspects of the tumor. Multiple myeloma is the most common plasmacytoma and its main feature is the infiltration of plasma cells into the bone marrow. Over 10% of plasma cell count among the nuclear cells in the bone marrow biopsy allows diagnosis of multiple myeloma. This involves multiple organs and extramedullary sites including the spleen, liver, lymph nodes and kidney; however, the involvement of nasal cavity and paranasal sinus is rare. Recently, we experienced a case of multiple myeloma, which was present in both nasal cavities and paranasal sinuses. The case was treated with chemotherapy and radiotherapy followed by autologous bone marrow transplantation. We report on it with literature review.

Hypoparathyroidism after Thyroidectomy and the Effect of Parathyroid Autotransplantation / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To preserve the parathyroid gland during thyroidectomy, understanding of its anatomy and physiology is essential. Parathyroid autotransplantation can be performed to restore the function of parathyroid gland. However, the efficacy of parathyroid autotransplantation is still debatable. The aim of this study was to analyze the frequency of hypoparathyroidism following thyroidectomy and evaluate the efficacy of parathyroid autotransplantation. SUBJECTS AND METHOD: We analyzed 449 patients who underwent thyroidectomy from January 2006 to June 2010. A total of 419 patients underwent total thyroidectomy, while 30 patients underwent unilateral lobectomy. Among the total thyroidectomy group, 96 patients underwent unilateral central neck dissection and 186 patients underwent bilateral central neck dissection. We analyzed the frequency of hypoparathyroidism according to the extent of thyroidectomy and central neck dissection, and parathyroid gland autotransplantation. RESULTS: Transient hypoparathyroidism occurred in 20% of lobectomy patients and 54.6% of the entire thyroidectomy group. Permanent hypoparathyroidism occurred only in 7.2% of the entire thyroidectomy group. Transient and permanent hypoparathyroidism occurred in 47.4% and 6.5%, respectively, of the patients without central neck dissection, in 54.0% and 7.3%, respectively, of the patients with unilateral central neck dissection, and 60.2% and 7.5%, respectively, of the patients with bilateral central neck dissection. Parathyroid autotransplantation was performed in 29 patients of 105 patients whose one or more parathyroid glands were removed inadvertently, and permanent hypoparathyroidism did not occur among those patients. CONCLUSION: The frequency of transient hypoparathyroidism was increased according to the extent of thyroidectomy and central neck dissection. Parathyroid autotransplantation might be effective in minimizing permanent hypoparathyroidism.

A Case of Intracranial Complication after Endoscopic Marsupialization of Frontal Sinus Mucocele / 대한이비인후과학회지

Frontal sinus mucocele is a slow-growing benign lesion, which can expand large enough to compress the orbit and intracranial structures. When mucocele develops symptoms, the surgical procedure should be considered. Complete resection of mucocele is one surgical procedure and marsupialization, which makes ventilator pathway and preserves the inner wall of mucocele, is another way. A recent study announced that marsupialization shows similar or better results compared to external resection. We present a case of frontal sinus mucocele, which developed intracranial complication after successful marsupialization.

Effects of Frontal Recess Cells on the Development of Frontal Sinusitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Frontal recess anatomy can be very complex, with accessory cells extending to the frontal sinus and possibly contributing to the obstruction of the frontal sinus. However, there is still controversy on the effect of the frontal recess cells. We designed this study to assess the effect of frontal recess cells on frontal sinusitis. SUBJECTS AND METHOD: We retrospectively reviewed chart and collected data of those who visited the outpatient clinic between January and June, 2011. Parnasal sinus CT was taken with Brillance 64-slice computed tomography scanners. The image was reviewed by two or more otolaryngologists to identify the frontal recess cells. The nasofrontal isthmus diameter and the area of nasofrontal isthmus was reconstructed and measured with workstation. Then, we compared the radiological results of frontal recess cells with the frequency of frontal sinusitis. RESULTS: The presence of anterior group of frontal recess cells showed no influence on the frontal recess anatomy. The presence of frontal bullar cell was significantly associated with the development of frontal sinusitis by simple (p=0.001) and multiple (p=0.038) logistic regression models. It was shown that the narrower the area of frontal isthmus the more developed were the frontal sinusitis, showing statistically significance in the simple (p=0.013) and multiple (p=0.017) logistic regression models. CONCLUSION: Our results also showed that similar results compared to previous Asianreport. The narrowness of nasofrontal isthmus could be the cause of frontal sinusitis. The frontal bullar cell could be the cause of frontal sinusitis encroaching on the frontal recess and affect the nasofrontal pathway.

Nasal and Exhaled Nitric Oxide in Allergic Rhinitis

OBJECTIVES: The primary aim of this study was to assess whether one can use levels of nasal nitric oxide (nNO) and exhaled nitric oxide (eNO) as a means of evaluation in allergic rhinitis. METHODS: We used a chemiluminescence analyzer to measure nNO and eNO in normal controls (n=34) and allergic rhinitis patients (n=35), and compared these measurements with various parameters of clinical symptoms and laboratory data. RESULTS: Mean nNO (389+/-119 ppb) in allergic rhinitis patients was significantly higher than normal controls (276+/-88 ppb). Without asthma, mean eNO (64.8+/-55.9 ppb) in allergic rhinitis patients was significantly higher than normal controls (33.0+/-24.0 ppb). In the persistent allergic rhinitis group, eNO concentration was significantly higher, while nNO concentration was significantly lower than the intermittent group. CONCLUSION: We can use nNO and eNO levels for evaluation of allergic rhinitis. However, we should consider the fact that nNO levels can be reduced, when symptoms are severe and long-lasting. Additionally, in allergic rhinitis, eNO can be elevated without asthma.

Comparative Analysis of the Expression of Involucrin, Filaggrin and Cytokeratin 4, 10, 16 in Cholesteatoma

BACKGROUND AND OBJECTIVES: The aim of this study is to determine whether the hyperproliferative and hyperkeratotic characters of cholesteatoma are associated with differentiation of keratinocytes in cholesteatoma by examining the localization of marker proteins, such as involucrin, filaggrin, and cytokeratins. MATERIALS AND METHODS: Immunohistochemical study was carried out in 30 cholesteatoma tissues and 10 retroauricular skins to examine the expression of involucrin, filaggrin, cytokeratin 4, 10 and 16. The staining results were graded as negative, weakly positive (70%). RESULTS: Involucrin was strongly expressed in upper spinous, granular, and corneal layer of cholesteatoma. Filaggrin was strongly expressed in granular and corneal layer of cholesteatoma. Cytokeratin 4 was expressed in basal layer of retroauricular skin, but occasionally expressed in suprabasal layer of cholesteatoma. Cytokeratin 10 was homogenously expressed in all suprabasal layer of retroauricular skin, whereas pattern of shift to surface layer was showed in cholesteatoma. Cytokeratin 16 was moderately expressed at suprabasal layer in cholesteatoma. CONCLUSIONS: It can be suggested that early differentiation of suprabasal layer may lead to hyperdifferentiation and hyperkeratosis. Different expression of cytokeratins possibly indicates the altered differentiation of cholesteatoma.