Comparison of Ramosetron Plus Dexamethasone with Ramosetron Alone on Postoperative Nausea, Vomiting, Shivering and Pain after Thyroid Surgery

BACKGROUND: Postoperative nausea and vomiting (PONV), postanesthetic shivering and pain are common postoperative patient complaints that can result in adverse physical and psychological outcomes. Some antiemetics are reported to be effective in the management of postoperative pain and shivering, as well as PONV. We evaluated the efficacy of dexamethasone added to ramosetron on PONV, shivering and pain after thyroid surgery. METHODS: One hundred and eight patients scheduled for thyroid surgery were randomly allocated to three different groups: the control group (group C, n = 36), the ramosetron group (group R, n = 36), or the ramosetron plus dexamethasone group (group RD, n = 36). The patients were treated intravenously with 1 and 2 ml of 0.9% NaCl (group C); or 2 ml of 0.15 mg/ml ramosetron plus 1 ml of 0.9% NaCl (group R); or 2 ml of 0.15 mg/ml ramosetron plus 1 ml of 5 mg/ml dexamethasone (group RD) immediately after anesthesia. RESULTS: Incidence of nausea and the need for rescue antiemetics, verbal rating scale (VRS) 1 hour pain value, ketorolac consumption, and incidence of shivering were significantly lower in group R and group RD, than in group C (P < 0.05). Moreover, these parameters were significantly lower in group RD than in group R (P < 0.05). CONCLUSIONS: Combination of ramosetron and dexamethasone significantly reduced not only the incidence of nausea and need for rescue antiemetics, but also the VRS 1 hour pain value, ketorolac consumption, and the incidence of shivering compared to ramosetron alone in patients undergoing thyroid surgery.

Surgical Findings to Differentiate Between Facial Nerve Schwannoma and Vestibular Schwannoma

OBJECTIVES: Facial nerve schwannomas may be misdiagnosed as vestibular schwannomas (VSs) if the tumor is confined to the internal auditory canal (IAC) without involvement the geniculated ganglion or labyrinthine segment of facial nerve. Because facial nerve schwannomas may be misdiagnosed as VSs, we investigated the differences between the two. METHODS: The study included 187 patients with a preoperative diagnosis of VS. Of these, six were diagnosed with facial nerve schwannomas during surgery. We reviewed the preoperative evaluations and surgical findings of facial nerve schwannomas mimicking VSs. RESULTS: No useful preoperative predictors are available for facial nerve schwannomas mimicking VSs. Facial nerve schwannomas are usually confined to the IAC. After opening the dura of the IAC, a facial nerve schwannoma can be diagnosed after identifying a normal-appearing nerve located lateral to the tumor. When this was the case, we performed facial nerve preservation surgery or decompression. CONCLUSION: Facial nerve schwannomas can be differentiated from VSs by identifying specific findings during surgery.

Mandibular condyle and infratemporal fossa reconstruction using vascularized costochondral and calvarial bone grafts

There are some difficulties in approaching and removing the lesion in infratemporal fossa because of its anatomical location. After wide excision of tumor lesion, it is also difficult for reconstruction of mandibular condyle and cranium base on infratemporal fossa. Besides, there are some possibilities of cerebrospinal fluid leakage, intracranial infection and bone resorption. It is also challenging for functional reconstruction that allows normal mandibular movement, preventing mandibular condyle from invaginating into the skull. In this report, we present 14-month follow-up results of a patient who had undergone posterior segmental mandibulectomy including condyle and infratemporal calvarial bone and mandible reconstruction with free vascularized costochondral rib and calvarial bone graft to restoration of the temporomandibular joint area.

Comparison of the efficacy of a forced-air warming system and circulating-water mattress on core temperature and post-anesthesia shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia / 대한마취과학회지

BACKGROUND: In the present study, we compared changes in body temperature and the occurrence of shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia during warming with either a forced-air warming system or a circulating-water mattress. METHODS: Forty-six patients were randomly assigned to either the forced-air warming system (N = 23) or circulating-water mattress (N = 23) group. Core temperature was recorded using measurements at the tympanic membrane and rectum. In addition, the incidence and intensity of post-anesthesia shivering and verbal analogue score for thermal comfort were simultaneously assessed. RESULTS: Core temperature outcomes did not differ between the groups. The incidence (13.0 vs 43.5%, P < 0.05) and intensity (20/2/1/0/0 vs 13/5/3/2/0, P < 0.05) of post-anesthesia shivering was significantly lower in the forced-air system group than in the circulating-water mattress group. CONCLUSIONS: The circulating-water mattress was as effective as the forced-air warming system for maintaining body temperature. However, the forced-air warming system was superior to the circulating-water mattress in reducing the incidence of post-anesthesia shivering.

Change in Tinnitus after Treatment of Vestibular Schwannoma: Microsurgery vs. Gamma Knife Radiosurgery

PURPOSE: Tinnitus is a very common symptom of vestibular schwannoma, present in 45 to 80% of patients. We evaluated changes in tinnitus after translabyrinthine microsurgery (TLM) or gamma knife radiosurgery (GKS). MATERIALS AND METHODS: Among 78 patients with vestibular schwannoma who underwent TLM or GKS at Severance Hospital from 2009-2012, 46 patients with pre- or postoperative tinnitus who agreed to participate were enrolled. Pure tone audiometry, tinnitus handicap inventory (THI), visual analogue scale (VAS) scores for loudness, awareness, and annoyance were measured before and after treatment. Changes of THI and VAS were analysed and compared according to treatment modality, tumour volume, and preoperative residual hearing. RESULTS: In the TLM group (n=27), vestibulocochlear nerves were definitely cut. There was a higher rate of tinnitus improvement in TLM group (52%) than GKS group (16%, p=0.016). The GKS group had a significantly higher rate of tinnitus worsening (74%) than TLM group (11%, p<0.001). Mean scores of THI and VAS scores significantly decreased in the TLM group in contrast to significant increases in the GKS group. Tumor volume and preoperative hearing did not affect the changes in THI or VAS. CONCLUSION: GKS can save vestibulocochlear nerve continuity but may damage the cochlea, cochlear nerve and can cause worsening tinnitus. In cases where hearing preservation is not intended, microsurgery with vestibulocochlear neurectomy during tumor removal can sometimes relieve or prevent tinnitus.

Radiologic Characteristics in a Case of Facial Nerve with Multisegment Involvement / 대한이비인후과학회지

A 47-year-old female patient presented with an acute onset of facial palsy and otitis media on the left side. Temporal bone CT scans revealed an irregularly shaped lesion in the middle ear cavity extending into the mastoid air cells. MRI images confirmed intra- and extra-temporal involvement of the facial nerve schwannoma. The correlation of distinct imaging findings of the facial nerve schwannoma along the course of the facial nerve and anatomical features of the temporal bone is discussed.

Leiomyosarcoma of the Middle Ear and Temporal Bone

Leiomyosarcoma is a malignant tumor of smooth muscle cells that is exceedingly rare in the middle ear and temporal bone. Wide surgical resection is treatment of choice and adjuvant treatment has not proven to be of benefit. This is a report on a patient with otorrhea and rapidly growing mass on postauricualr area. A tumor that was mainly located in the middle ear and temporal bone was surgically removed and proved to be a leiomyosarcoma. The optimal surgical technique and other treatment strategy are discussed.

Unidirectional valve malfunction by the breakage or malposition of disc: two cases report / 대한마취과학회지

Malfunction of the unidirectional valve in a breathing circuit system may cause hypercapnia from the rebreathing of expired gas, ventilation failure, and barotrauma. Capnography is a useful method for monitoring the integrity of the unidirectional valve. We experienced two cases of malfunction of a unidirectional valve which caused leakage and reverse flow, diagnosed early as a change of the capnographic waveform. One case was caused by expiratory unidirectional valve breakage. The other was caused by an incorrectly-assembled inspiratory unidirectional valve.

Bimodal Benefits on Objective and Subjective Outcomes for Adult Cochlear Implant Users

BACKGROUND AND OBJECTIVES: Given that only a few studies have focused on the bimodal benefits on objective and subjective outcomes and emphasized the importance of individual data, the present study aimed to measure the bimodal benefits on the objective and subjective outcomes for adults with cochlear implant. SUBJECTS AND METHODS: Fourteen listeners with bimodal devices were tested on the localization and recognition abilities using environmental sounds, 1-talker, and 2-talker speech materials. The localization ability was measured through an 8-loudspeaker array. For the recognition measures, listeners were asked to repeat the sentences or say the environmental sounds the listeners heard. As a subjective questionnaire, three domains of Korean-version of Speech, Spatial, Qualities of Hearing scale (K-SSQ) were used to explore any relationships between objective and subjective outcomes. RESULTS: Based on the group-mean data, the bimodal hearing enhanced both localization and recognition regardless of test material. However, the inter- and intra-subject variability appeared to be large across test materials for both localization and recognition abilities. Correlation analyses revealed that the relationships were not always consistent between the objective outcomes and the subjective self-reports with bimodal devices. CONCLUSIONS: Overall, this study supports significant bimodal advantages on localization and recognition measures, yet the large individual variability in bimodal benefits should be considered carefully for the clinical assessment as well as counseling. The discrepant relations between objective and subjective results suggest that the bimodal benefits in traditional localization or recognition measures might not necessarily correspond to the self-reported subjective advantages in everyday listening environments.

Effect of position changes after spinal anesthesia with low-dose bupivacaine in elderly patients: sensory block characteristics and hemodynamic changes / 대한마취과학회지

BACKGROUND: The purpose of this study is to compare the anesthetic characteristics in elderly patients who remain in sitting position for 2 min compared with patients that are placed in supine position after induction of spinal anesthesia. METHODS: Fifty-seven patients scheduled for transurethral surgery were randomized to assume supine position immediately after 6.5 mg hyperbaric bupivacaine were injected (L group) or to remain in the sitting position for 2 minutes before they also assumed the supine position (S group). Analgesic levels were assessed bilaterally, using pin-prick. Motor block was scored using a 12-point scale. The mean arterial pressure and heart rate were also recorded. RESULTS: Sensory block levels were significantly lower at all time points for the L group. However, there were no significant differences in the degree of the motor block and hemodynamic changes between the two groups. However, in the L group, ephedrine or atropine were administered to three patients. CONCLUSIONS: We concluded that performing a spinal anesthesia in sitting position was technically easier and induced less hypotension.

A Case of Inflammatory Pseudotumor in Temporal Bone Treated with Methotraxate / 대한이비인후과학회지

Inflammatory pseudotumor is a pathologically benign condition, but it demonstrates a wide range of clinical features ranging from silent small sized tumors to aggressive features mimicking malignancy. Pseudotumors most commonly occur in the orbital area, and the involvement of the middle ear cavity is extremely rare. Several modalities are known for the treatment of pseudotumors, including complete surgical excision, oral steroid therapy, and radiation therapy. We describe a 35-year-old woman with inflammatory pseudotumor involving the middle ear cavity. The patient was treated with canal wall up tympanomastoidectomy and additional treatments with steroid and radiation therapy. However, she showed side effects to high dose steroid treatment and no response to radiation therapy. Therefore, we decided to use methotrexate with low dose steroid. After treatment, symptoms were completely resolved and there was no evidence of recurrence 1 year after maintaining immunosuppressant treatment.

Multicenter Study on the Clinician's Diagnostic and Therapeutic Approaches for Benign Paroxysmal Positional Vertigo in Korea / 대한평형의학회지

BACKGROUND AND OBJECTIVES: It is necessary to establish the most efficient diagnostic and therapeutic method for benign paroxysmal positional vertigo (BPPV), which is appropriate for Korean healthcare system. We aimed to evaluate current state of Korean clinician's diagnostic and therapeutic approaches for BPPV. MATERIALS AND METHODS: A 16-item survey was emailed to the members of dizziness department of Otology Research Interest Group in the Korean Otologic Society (n=68). 43 were returned and analyzed. RESULTS: All respondents (100%) used Dix-Hallpike test as a diagnostic tool for vertical canal-BPPV. Supine roll test was used for diagnosing lateral canal BPPV in nearly all the respondents (97.7%). Epley maneuver was chosen as otolith repositioning maneuver (ORM) for posterior canal BPPV in all respondents and barbecue rotation (BBQ) was used for treating lateral canal BPPV with geotropic nystagmus in 95.3% of respondents. Extreme variation was noted for therapeutic approach of lateral canal BPPV with ageotropic nystagmus BBQ, with 4 kinds of ORM and adjunctive measures to liberate otolith from cupula, while BBQ was again the most commonly used ORM (76.7%). CONCLUSION: The development of practical and efficient ORM for lateral canal BPPV with ageotropic nystagmus is necessary.

A Case of Cerebral Salt Wasting Syndrome after Surgical Excision of a Giant Acoustic Neuroma / 대한이비인후과학회지

Cerebral Salt Wasting Syndrome (CSWS) is defined as the development of extracellular volume depletion due to a dysfunction of the renal sodium transport system. Differentiation of CSWS from the Symdrome of Inappropriate Secretion of Antidiuretic Hormone in patients with intracranial disease is difficult because both syndromes include hyponatremia and concentrated urine with natriuresis. However, distinguishing between these two syndromes is very important because the treatment options differ. We report a 41 year-old Asian woman who presented initially with hyponatremia, and was finally diagnosed with CSWS after an operation for an acoustic neuroma. Based on this case, we discuss a possible mechanism and disclose insights about differential diagnosis thereof.

Nasal Colonization of Methicillin-Resistant Staphylococcus aureus in Patients with Chronic Suppurative Otitis Media

BACKGROUND AND OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is one of major pathogens in patients with chronic suppurative otitis media (CSOM). In addition to intrinsic MRSA infection of the mastoid air cell system, nasal colonization of MRSA, a known predictor of postoperative surgical site infection, may pose increased risk of postoperative complications. The purpose of this study is to describe microbiology of preoperative nasal swab screening and localized middle ear specimens in patients undergoing otologic surgeries. SUBJECTS AND METHODS: Forty-nine consecutive patients with CSOM who underwent middle ear surgery were included. Preoperative nasal swabs for MRSA, and preoperative and intraoperative middle ear swabs were collected and compared for pathogens. RESULTS: Preoperative nasal swab screening confirmed MRSA colonization in 3/49 patients (6.1%) and methicillin-resistant coagulase-negative Staphylococcus (MRCNS) in 9/49 patients (18.4%). Correlation with preoperative culture results and nasal swab screening results were compatible in 2/4 patients with positive nasal swab for MRSA and 1/9 patients with positive nasal swab for MRCNS. Postoperative conversion to MRSA was observed in 3 patients. CONCLUSIONS: The rate of nasal MRSA colonization among patients with CSOM was higher than among the general community. Preoperative MRSA colonization was associated with MRSA from middle ear specimens. Further studies are warranted to investigate the possible benefit of preoperative treatment of MRSA colonized patients undergoing middle ear surgeries.

Facial Nerve Paralysis due to Chronic Otitis Media: Prognosis in Restoration of Facial Function after Surgical Intervention

PURPOSE: Facial paralysis is an uncommon but significant complication of chronic otitis media (COM). Surgical eradication of the disease is the most viable way to overcome facial paralysis therefrom. In an effort to guide treatment of this rare complication, we analyzed the prognosis of facial function after surgical treatment. MATERIALS AND METHODS: A total of 3435 patients with COM, who underwent various otologic surgeries throughout a period of 20 years, were analyzed retrospectively. Forty six patients (1.33%) had facial nerve paralysis caused by COM. We analyzed prognostic factors including delay of surgery, the extent of disease, presence or absence of cholesteatoma and the type of surgery affecting surgical outcomes. RESULTS: Surgical intervention had a good effect on the restoration of facial function in cases of shorter duration of onset of facial paralysis to surgery and cases of sudden onset, without cholesteatoma. No previous ear surgery and healthy bony labyrinth indicated a good postoperative prognosis. CONCLUSION: COM causing facial paralysis is most frequently due to cholesteatoma and the presence of cholesteatoma decreased the effectiveness of surgical treatment and indicated a poor prognosis after surgery. In our experience, early surgical intervention can be crucial to recovery of facial function. To prevent recurrent cholesteatoma, which leads to local destruction of the facial nerve, complete eradication of the disease in one procedure cannot be overemphasized for the treatment of patients with COM.

Evaluation of Trigeminal Nerve Involvement Using Blink Reflex Test in Bell's Palsy

BACKGROUND AND OBJECTIVES: Facial nerve dysfunction in Bell's palsy is evaluated using various parameters including physical examination and electrophysiological studies. Associated symptoms of facial numbness or paresthesia are reported by some patients with Bell's palsy. The aim of this study was to investigate trigeminal nerve involvement in Bell's palsy using blink reflex test. SUBJECTS AND METHODS: Facial nerve and trigeminal nerve functions were assessed using House-Brackmann (HB) grading system, electroneuronography (ENoG) and blink reflex tests in 28 patients diagnosed as Bell's palsy. RESULTS: HB grades correlated with degeneration ratio from ENoG (p=0.002, chi-square test). The ipsilateral R1 reponse of the blink reflex was absent or abnormal in 27/28 patients (96.4%), and ipsilateral R2 response was absent or abnormal in 26/28 patients (92.8%). Contralateral R2 was abnormal in 5/28 patients (17.8%), suggesting involvement of trigeminal nerve in a portion of patients. The results of blink reflex test showed no significant correlation to the outcome of facial nerve function (HB grade) in Bell's palsy patients. CONCLUSIONS: Blink reflex test provides information about trigeminal and facial nerve functions in addition to ENoG results. Our study suggests that subclinical involvement of trigeminal nerve may accompany facial nerve dysfunction in Bell's palsy.

What Causes Incomplete Facial Function Recovery in Patients with Immediate Facial Paralysis Following Vestibular Schwannoma Surgery?

BACKGROUND AND OBJECTIVES: Preservation of facial nerve function in vestibular schwannoma (VS) surgery is still a significant operative challenge. Several prognostic factors correlate with postoperative facial nerve function. Most partial facial nerve damage can recover completely without functional defect. However, recovery of the facial nerve in some patients is either incomplete or non-existent. To evaluate the cause of incomplete facial function recovery at long term follow-up (> or =1 year), we analyzed the factors that influenced facial function recovery in a consecutive series of patients that had immediate post-operative, partial paralysis after VS surgery with preservation of neural integrity. MATERIALS AND METHODS: We conducted a retrospective review of 143 cases of VS surgery that occurred between January 1994 and December 2008. Twenty-seven patients that had immediate, postoperative partial facial paralysis and normal preoperative facial function with intact nerve after tumor excision were analyzed with regards to age, sex, tumor size, tumor location, internal auditory canal (IAC) widening, duration of surgical procedure, postoperative complication, and facial function after a postoperative follow-up period of > or =1 year by the House-Brackmann (HB) grading system. RESULTS: Of the 143 patients that underwent VS surgery, 27 (18.8%) patients had immediate, postoperative partial facial paralysis. At long-term follow-up, there were 11 (7.6%) patients with incomplete facial recovery. Facial function recovery after facial nerve injury did not show a significant difference in tumor size, surgical approach, or tumor location. However, preoperative IAC widening and the duration of the procedure were related to facial restoration after surgery. CONCLUSIONS: The injured facial nerve during VS surgery showed incomplete recovery in many cases. Chronic compression of the facial nerve, together with IAC widening preoperatively, led to incomplete restoration of injured facial nerves.

What Causes Incomplete Facial Function Recovery in Patients with Immediate Facial Paralysis Following Vestibular Schwannoma Surgery?

BACKGROUND AND OBJECTIVES: Preservation of facial nerve function in vestibular schwannoma (VS) surgery is still a significant operative challenge. Several prognostic factors correlate with postoperative facial nerve function. Most partial facial nerve damage can recover completely without functional defect. However, recovery of the facial nerve in some patients is either incomplete or non-existent. To evaluate the cause of incomplete facial function recovery at long term follow-up (> or =1 year), we analyzed the factors that influenced facial function recovery in a consecutive series of patients that had immediate post-operative, partial paralysis after VS surgery with preservation of neural integrity. MATERIALS AND METHODS: We conducted a retrospective review of 143 cases of VS surgery that occurred between January 1994 and December 2008. Twenty-seven patients that had immediate, postoperative partial facial paralysis and normal preoperative facial function with intact nerve after tumor excision were analyzed with regards to age, sex, tumor size, tumor location, internal auditory canal (IAC) widening, duration of surgical procedure, postoperative complication, and facial function after a postoperative follow-up period of > or =1 year by the House-Brackmann (HB) grading system. RESULTS: Of the 143 patients that underwent VS surgery, 27 (18.8%) patients had immediate, postoperative partial facial paralysis. At long-term follow-up, there were 11 (7.6%) patients with incomplete facial recovery. Facial function recovery after facial nerve injury did not show a significant difference in tumor size, surgical approach, or tumor location. However, preoperative IAC widening and the duration of the procedure were related to facial restoration after surgery. CONCLUSIONS: The injured facial nerve during VS surgery showed incomplete recovery in many cases. Chronic compression of the facial nerve, together with IAC widening preoperatively, led to incomplete restoration of injured facial nerves.

What Really Decides the Facial Function of Vestibular Schwannoma Surgery?

OBJECTIVES: To find the main cause of facial nerve dysfunction in vestibular schwannoma (VS) surgery and review the prognosis of facial function in relation to tumor size, preoperative facial function and surgical approach. METHODS: We reviewed the surgical outcome of 134 patients with VS treated in our department between 1994 and 2008. All patients included in the study had postoperative facial paralysis after surgical management of their VS. There were 14 women and 7 men. The mean age was 48.5 years, with a mean follow-up period of 57 months. RESULTS: Twenty-one patients (sustained facial palsy, 4; newly developed facial palsy, 17) had facial nerve paralysis after surgery: ten patients in large VS and eleven patients in small VS. In large VS group, 4 patients had facial nerve function of HB grade II, 3 patients had HB grade III, and 3 patients had HB grade IV. In small VS group, 9 patients had HB grade II and 2 patients had HB grade IV. Middle cranial fossa approach rather than translabyrinthine approach for the preservation of hearing, led to facial nerve deterioration and the patients who had facial nerve paralysis perioperatively, had resulted in permanent facial paralysis. CONCLUSION: The tumor size in VS is certainly one of the most important prognostic factors. However, VS tumor size alone should not be considered a unique prognostic indicator. The surgical approach used, which may be related to tumor size, based on the surgeon's experience, can be a deciding factor, and the status of the facial nerve injured by the tumor can influence postoperative facial nerve function.

Uridine-5'-Triphosphate Stimulates Chloride Secretion via Cystic Fibrosis Transmembrane Conductance Regulator and Ca2+-Activated Chloride Channels in Cultured Human Middle Ear Epithelial Cells / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Nucleotide binding to purinergic P2Y receptors contributes to the regulation of fluid and ion transport in the middle ear epithelial cells. Here, we investigated the regulatory mechanism of the P2Y2 receptor agonist, uridine-5'-triphosphate (UTP), on Cl- transport in cultured normal human middle ear epithelial (NHMEE) cells. MATERIALS AND METHOD: Electrophysiological measurements were performed in monolayers of cultured NHMEE cells. Short circuit currents (Isc) were measured from the cells mounted in Ussing chambers under various conditions. RESULTS: Apical addition of UTP in presence of amiloride evoked a transient rise and a sustained response in Isc due to Cl- efflux. Application of different Cl- channel blockers to the apical side of the cells significantly decreased UTP-induced Isc. Niflumic acid (NFA), a known blocker of Ca(2+)-activated chloride channels (CACC), and CFTRinh172, a selective inhibitor of cystic fibrosis transmembrane conductance regulator (CFTR), partially inhibited the UTP-induced Cl- secretion, respectively. CONCLUSION: Cl- transport across the airway epithelia plays a predominant role in regulating airway hydration. In this study, UTP is shown to increase both CACC and CFTR-dependent Cl- secretion in NHMEE cells, suggesting their role in fluid and ion transport in the middle ear epithelium.