A Case With Herpes Zoster Ophthalmicus Mimicking Delayed Complication of Rhinoplasty

Herpes zoster ophthalmicus (HZO) occurs due to reactivation of dormant varicella zoster virus infection in the ophthalmic division of the trigeminal nerve. Hutchinson’s sign, a herpetic skin lesion in the nasal tip, is a predictor of ocular complications, as the nasal tip area and ocular structure are innervated by the same nasociliary nerve. Patients who present with Hutchinson’s sign should be referred to an ophthalmologist due to possibility of ocular complications. Here, we present a case of a 44-year-old man with HZO that was confused with delayed rhinoplasty complication. The patient presented with nasal tip skin lesions 17 years after undergoing augmentation rhinoplasty. A graft-related infection was suspected due to operation history and skin lesions. However, surgical exploration disclosed no infection or inflammation, and serological tests revealed positive varicella zoster virus immunoglobulin M, and immunoglobulin G, antibodies. Based on these findings, the patient was diagnosed with HZO. Further, the patient received antiviral treatment with famciclovir. The lesions gradually improved with conservative treatment and became almost unrecognizable. Therefore, HZO should be considered when there is an unexplained skin lesion at the nasal tip in patients with history of rhinoplasty.

Evaluation of the Esthetic and Functional Outcomes of Extracorporeal Septoplasty for Rhinoplasty in Asian Patients

Objectives@#. In extracorporeal septoplasty (ECS), the entire septal cartilage is harvested, and a neo-L strut is built extracorporeally. Thus, ECS can simultaneously achieve septum straightening and tip projection. This study evaluated the functional and esthetic outcomes of the ECS technique for rhinoplasty in Asian patients. @*Methods@#. We conducted a retrospective review of 64 patients who underwent rhinoplasty using ECS between January 2016 and March 2018. Subjective patient satisfaction was assessed and objective surgical outcomes were evaluated. Improvement in nasal obstruction was rated using a visual analog scale (VAS). Anthropometric changes were compared between preoperative and postoperative facial photographs. Complications and revisions were also analyzed. @*Results@#. The participants comprised 64 patients (48 males and 16 females, with a mean age of 29.3 years). The mean operative time was 89.3 minutes. In total, 61 patients were satisfied with the esthetic outcome, and the overall objective rhinoplasty outcome score was 3.45. Preoperative nasal obstruction symptoms (7.9±1.2 on VAS) improved postoperatively (3.1±1.3, P<0.001), and significant improvements were also observed in the nasofrontal angle (152.3° to 148.1°, P<0.001), nasolabial angle (88.8° to 92.0°, P<0.001), and nasal tip projection (0.62 to 0.66, P<0.033). Recurrent deviation of the nasal septum and external nose or tip deprojection did not occur in any patients, and there were no cases of revision during the mean follow-up period of 13.3 months. @*Conclusion@#. ECS might be an esthetically and functionally satisfactory alternative rhinoplasty technique for Asian patients with a shortage of septal cartilage.

Long-term Breastfeeding in the Prevention of Allergic Rhinitis: Allergic Rhinitis Cohort Study for Kids (ARCO-Kids Study)

OBJECTIVES: There is a great deal of interest in the possibility that environmental factors may influence the risk of developing allergic rhinitis (AR) in early life. We investigated the simultaneous effects of mode of delivery and duration of breastfeeding on the development of AR in children. METHODS: Data from 1,374 children participating in the Allergic Rhinitis Cohort Study for kids (ARCO-kids study) was analyzed. All subjects were divided into AR or non-allergic rhinitis (NAR) groups. Data on environmental factors, mode of delivery and duration of breastfeeding were collected using a questionnaire. RESULTS: Compared with short-term breastfeeding (<6 months), long-term breastfeeding (≥12 months) was significantly associated with a lower prevalence of AR (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.34 to 0.88). Children in the AR group also had a higher cesarean delivery rate than those in the NAR group (39.1% vs. 32.8%, P=0.05). Regarding the combined effects of mode of delivery and duration of breastfeeding, long-term breastfeeding with a vaginal delivery strongly suppressed the development of AR, compared to short-term breastfeeding with a cesarean delivery (aOR, 0.47; 95% CI, 0.30 to 0.73). CONCLUSION: Long-term breastfeeding (≥12 months) and a vaginal delivery are associated with a lower risk of developing childhood AR.

Management of Orbital Blowout Fractures: ENT Surgeon's Perspective

Reduction of Isolated Zygomatic Arch Fractures with Gillies Approach / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The incidence of facial bone fracture is increasing. The zygomatic bone, due to its anatomical prominence, is the second most common site of all facial bone fractures. In this study, we present the clinical experiences of zygomatic arch fracture in a tertiary hospital and introduce the Gillies approach for reduction and its outcome results. SUBJECTS AND METHOD: We collected data from retrospective chart reviews of patients who underwent surgeries from 2010 to 2017 for zygomatic arch fractures at Chungbuk National University Hospital. Data were analyzed according to age, gender, cause of trauma, location of trauma, and clinical symptoms including trismus. All surgery was performed under general anesthesia and via the use of Gillies approach. The result of surgery was evaluated by postoperative facial computed tomography. RESULTS: Sixteen patients underwent surgery for zygomatic arch fracture. The patients had the average age of 41.3 years, a male predominance of 15:1 and physical assault as the most common cause of trauma. The time lag between injury and surgical reduction was 5.5 days. The surgical outcomes were assessed “good” in 14 cases and “moderate” in one case. Patients who had trismus preoperatively were resolved of it in all cases after operation. Postoperative complications were absent. CONCLUSION: The Gillies approach proved to be a relatively easy, safe, and reliable method, and its surgical outcomes was satisfactory in our experiences.

Corrective Septorhinoplasty in Acute Nasal Bone Fractures

OBJECTIVES: Closed reduction is generally recommended for acute nasal bone fractures, and rhinoplasty is considered in cases with an unsatisfactory outcome. However, concomitant rhinoplasty with fracture reduction might achieve better surgical outcomes. This study investigated the surgical techniques and outcomes in patients who underwent rhinoplasty and fracture reduction concomitantly, during the acute stage of nasal bone fracture. METHODS: Forty-five patients who underwent concomitant rhinoplasty and fracture reduction were enrolled. Nasal bone fractures were classified into three major types (type I, simple fracture; type II, fracture line that mimics nasal osteotomy; and type III, comminuted fracture) based on computed tomography images and preoperative facial images. Two independent otolaryngology-head and neck surgeons evaluated the surgical outcomes and telephone based survey were made to evaluate patients satisfaction. RESULTS: Among 45 patients, there were 39 males and 6 females. Type I was the commonest type of fracture with 18 patients (40%), while the most frequently used surgical technique for corrective surgery was dorsal augmentation with 44 patients (97.8%). The mean visual analogue scale satisfaction score of the surgeons and patients were 7.62 and 8, respectively, with no significant differences between fracture types. CONCLUSION: Concomitant rhinoplasty with fracture reduction can be performed for acute nasal bone fracture patients, and it might lead to better aesthetic outcomes.

A Systematic Review of Benefit of Silicone Intubation in Endoscopic Dacryocystorhinostomy

OBJECTIVES: Insertion of a silicone stent during endoscopic dacryocystorhinostomy (DCR) is the most common procedure to prevent rhinostomy closure. It has been claimed that silicone intubation improves the surgical outcomes of endoscopic DCR. However, many reports have documented an equally high success rate for surgery without silicone intubation. Accordingly, we conducted a systematic review and meta-analysis to clarify the outcomes of endoscopic DCR with and without silicone intubation and determine whether silicone intubation is actually beneficial for patients. METHODS: PubMed, Embase, and Cochrane Library databases were searched to identify relevant controlled trials evaluating endoscopic DCR with and without silicone intubation. The search was restricted to English articles published between January 2007 and December 2016. Relevant articles were reviewed to obtain information pertaining to interventions and outcomes. We also performed a meta-analysis of the relevant literature. RESULTS: In total, 1,216 patients included in 12 randomized controlled trials were pooled. A total of 1,239 endoscopic DCR procedures were performed, and silicone stents were used in 533 procedures. The overall success rate for endoscopic DCR was 91.9% (1,139/1,239), while the success rates with and without silicone intubation were 92.9% (495/533) and 91.2% (644/706), respectively. There was no statistically significant heterogeneity among the included studies. A meta-analysis using a fixed-effects models showed no significant difference in the success rate between endoscopic DCR with silicone intubation and that without silicone intubation (OR, 1.38; 95% CI, 0.89 to 2.12; P=0.148; z=1.45). Furthermore, there were no significant differences with regard to surgical complications such as synechia, granulation, and postoperative bleeding. CONCLUSION: The findings of our meta-analysis suggest that the success rate and postoperative complication rate for endoscopic DCR is not influenced by the use of silicone intubation during the procedure.

Effect of a Chitosan Gel on Hemostasis and Prevention of Adhesion After Endoscopic Sinus Surgery

OBJECTIVES: Postoperative bleeding and adhesion formation are the two most common complications after endoscopic sinus surgery (ESS). The former sometimes can be life threatening and the latter is the most common reason requiring revision surgery. This study was designed to evaluate the effect of newly developed chitosan gel (8% carboxymethyl chitosan, Surgi shield) on hemostasis and wound healing after ESS. METHODS: A prospective, randomized, double-blind controlled trial was conducted in 33 patients undergoing symmetric ESS. At the conclusion of the operation, Surgi shield was randomly applied on one side of the nasal cavity, with the opposite side acting as control and the bleeding quantity of the surgical field was evaluated every 2 minutes. And then, Merocel was placed in the ethmoidectomized areas of the both sides. Five milliliters of Surgi shield was applied to the Merocel of intervention side and saline was applied to the other side. Merocel in both nasal cavities was removed and 5 mL of Surgi shield was applied again to the intervention side on the second day after surgery. The nasal cavity was examined using a nasal endoscope and the degree of adhesion, crusting, mucosal edema, infection, and granulations were graded at 1, 2, and 4 weeks after surgery. RESULTS: Complete hemostasis was rapidly achieved in the Surgi shield applied side compared with the control side at 2, 4, 6, 8, and 10 minutes after application of Surgi shield (P#x0003d;0.007, P#x0003d;0.004, P0.05). No adverse effects were noted in the patient series. CONCLUSION: Surgi shield containing chitosan can be used safely to achieve rapid hemostasis immediately after ESS and to prevent adhesion formation.

Two Cases of Combined Orbital Fractures Involving Medial Wall, Inferior Wall and Inferomedial Strut / 대한이비인후과학회지

Surgical treatment of combined orbital floor and medial wall fractures involving inferomedial strut can be technically challenging because of absent peripheral bony support for implants. These fractures were conventionally reconstructed with some implants for reconstruction of inferior and medial wall through the external approach. Preparing accurate 3-dimentional implants is time-consuming and inserting large implants through a limited incision site is also troublesome. The authors present two cases of this type of fracture that are successfully repaired using a new strategy by separately repairing the medial and inferior wall combined with inferomedial strut reduction.

Two Cases of Epiphora Following Le Fort I Osteotomy / 대한이비인후과학회지

The lacrimal drainage system begins at the puncta and empties through the valve of Hasner into the inferior meatus. The varieties of the anatomic location, size and morphology of this valve can predispose susceptible individuals to an increased incidence of iatrogenic injury during nasal surgical procedures, thus necessitating a comprehensive understanding of the system. We report two cases of epiphora following two-jaw surgeries for cosmetic purposes. Nasolacrimal duct obstructions were diagnosed, and the symptoms were improved with dacryocystorhinostomies.

A Case of Churg-Strauss Syndrome Involving Nasal Cavity / 대한이비인후과학회지

Churg-Strauss syndrome is a rare systemic vasculitis occurring in patients with asthma and peripheral eosinophilia. Lungs, skin, and the nervous system are the most common sites of involvement, although many other organs are affected frequently. We report a case of 54-year-old male with a history of asthma and chronic rhinosinusitis who was admitted to the emergency department because of dyspnea and pleural pain. He was diagnosed with Churg-Strauss syndrome based on bronchial asthma, peripheral eosinophilia, pulmonary infiltration, chronic rhinosinusitis, and extravascular eosinophil infiltration. His symptoms were resolved dramatically after treatment with corticosteroids. Allergic rhinitis and chronic rhinosinusitis with or without polyps may be present at the early stage of Churg-Strauss syndrome. Therefore, otolaryngologists may play a pivotal role in making an early diagnosis of this disease.

The effect of xylometazoline spray for expansion of nasal cavity / 대한마취과학회지

BACKGROUND: During nasotracheal intubation it is important to have proper pretreatment for nasal mucosa constriction and nasal cavity expanding. Nasal packing of epinephrine gauze is widely used as well as xylometazoline. The aim of this study was to compare and evaluate the efficacy of prophylactic intranasal spray of xylometazoline against epinephrine gauze packing in expanding the nasal cavity. METHODS: Volunteers (n = 32) in their twenties without nasal disease such as septal deviation or rhinitis were enrolled in the study. The more patent nostril in each subject was measured by acoustic rhinometry as the base value. After intranasal spray of xylometazoline, the same nostril was remeasured by same method. Twenty four hours later, intranasal packing of epinephrine gauze was done and the same treatment was done. Subject preferences about the procedures were asked. RESULTS: There were significant difference among treatments (base value: 0.582 +/- 0.164 cm2, xylometazoline spray: 0.793 +/- 0.165 cm2, epinephrine gauze packing: 0.990 +/- 0.290 cm2) in acoustic rhinometry. While the epinephrine gauze packing showed more efficient mucosa constriction, subjects preferred xylometazoline spray. CONCLUSIONS: Even though xylometazoline spray was less effective than epinephrine gauze packing, the simplicity and convenience compensated. In patients undergoing nasotracheal intubation, xylometazoline spray can be an alternative to epinephrine gauze packing.

Endoscopic Endonasal Reduction of Medial Blow Out Fracture Using Nasopore Forte(R) / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Before the introduction of transnasal endoscopic sinus surgery, transorbital approach with an external incision used to be one of the representative reconstructive surgical repairing method of blow out fracture. The important advantages of transnasal endoscopic technique are magnified direct visualization and easy accessibility to the medial orbital wall. Nasopore Forte(R) is a slowly absorbable material and provides excellent durability. The purpose of this study is to evaluate outcomes of endoscopic endonasal reduction (EER) of medial blow out fracture using Nasopore Forte(R). SUBJECTS AND METHOD: A retrospective study was performed on 26 patients with medial blowout fracture who had undergone EER using Nasopore Forte(R) from January to December of 2010 at our clinic. A review of medical records included demographic data, preoperative ocular symptoms and signs, and surgical outcomes including postoperative symptom improvement and complications. RESULTS: Of 26 patients, 5 had persistent diplopia, 5 enophthalmos, and 3 both diplopia and enophthalmos preoperatively. Seventeen patients were asymptomatic, but had large defects with the mean defect size of 2.4 cm2. Postoperative computed tomography scan showed excellent (22) to good (4) reduction. Preoperative symptoms were resolved in all of 13 symptomatic patients and there was no enophthalmos during the follow-up period. No significant complications including sinusitis or synechia were found. CONCLUSION: EER is a highly effective and safe procedure for the reduction of medial blow out fracture. Nasopore Forte(R) is easy to handle and can be tailored to individual defects, and is useful for securing the reduction and preventing adhesion after EER.

Nasolacrimal Duct Obstruction Following Midfacial Autologous Fat Injection / 대한이비인후과학회지

Epiphora is usually caused by nasolacrimal duct obstruction. The nasolacrimal duct obstruction is related with facial trauma, other nasal or paranasal sinus diseases, or recurrent dacryocystitis. We describe a case of iatrogenic nasolacrimal duct obstruction that occurred secondary to midfacial autologous fat injection. In our case, mal positioned fat tissue was detected on the dacryocystogram to be present in the lacrimal sac and the nasolacrimal duct. They were safely removed during dacryocystorhinostomy.

Kawasaki Disease Presenting as Cervical Lymphadenitis and Retropharyngeal Abscess / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Kawasaki diseases (KD) sometimes present themselves as cervical lymphadenitis or deep neck infection. These unusual Kawasaki diseases then lead to unnecessary antibiotic therapy or surgical intervention or delaying therapy. The purpose of this study is to determine clinical characteristics of early expressions of atypical Kawasaki diseases presenting as deep neck infection. SUBJECTS AND METHOD: We reviewed the medical records of the 6 patients who had been treated for Kawasaki disease that initially presented as fever and cervical lymphadenitis between March, 2007 and December, 2008. RESULTS: The contrast neck CT scan of four of the cases revealed no ring enhancement but retropharyngeal space fluid collection suggestive of retropharyngeal abscess. The contrast neck CT scan of the other two cases showed homogenous nonsuppurative cervical lymph node enlargement. We administered intravenous antibiotics but patients did not response to them. We then immediately administered intravenous immunoglobulin and aspirin after making the diagnosis of Kawasaki disease. The clinical condition of all the cases improved dramatically with defervescence. CONCLUSION: The possibility of Kawasaki disease should be considered in the following three situations: first, if the fever is refractory to intravenous antibiotic treatment in the febrile child with cervical lymphadenopathy, secondly, if the neck CT scan reveals a soft tissue swelling with no ring enhancement, and lastly, if the fever subsides dramatically after starting intravenous immunoglobulin and aspirin. Echocardiography should be performed as early as possible.

A Case of Streptococcus salivarius Meningitis in a Patient with Cerebrospinal Fluid Rhinorrhea after Skull Base Fracture / 대한임상미생물학회지

Streptococcus salivarius meningitis is very uncommon, and most cases are iatrogenic, occurring after invasive procedures such as spinal anesthesia or lumbar puncture etc.. Post-traumatic occurrence of this infection is especially rare. A 20-year-old man with a previous history of skull base fracture was seen at the emergency department with signs of acute bacterial meningitis. The CSF had a few gram positive cocci with neutrophilic pleocytosis, which were identified as S. salivarius by the Vitek system (bioMerioux, Inc., Hazelwood, MO, USA), rapid ID 32 Strep (bioMerieux, Marcy-l'Etoile, France) and 16S rRNA sequencing. The microorganism showed intermediate resistance to penicillin (MIC=0.25 microg/mL) but was susceptible to cefotaxime (MIC=0.25 microg/mL) and vancomycin (MIC= 0.75 microg/mL). The patient was treated with ceftriaxone and vancomycin. He also had his CSF leakage repaired by an endoscopic approach. To our knowledge, this is the first case of S. salivarius meningitis reported in Korea.

The Surgical Outcome of Endoscopic Dacryocystorhinostomy According to the Obstruction Levels of Lacrimal Drainage System

OBJECTIVES: Many factors influence the outcome of endoscopic dacryocystorhinostomy (DCR). One of the most important prognostic factors is the level of obstruction in the lacrimal drainage system. The main objective of this report is to evaluate both the frequency of obstruction by anatomical region of the lacrimal drainage system on dacryocystography (DCG) and the surgical outcome of endoscopic DCR according to the obstruction level. METHODS: A retrospective series of 48 patients (60 eyes) who had undergone endoscopic DCR from January 2005 to November 2007 were enrolled. Preoperative evaluation consisted of a standard examination which included lacrimal irrigation, probing, DCG and osteomeatal unit (OMU) computed tomography. Patients were classified into four groups according to the obstruction level on DCG. Surgical outcome was evaluated postoperatively by subjective improvement of epiphora and patent rhinostomy opening on nasal endoscopic exam. RESULTS: Of 60 eyes, the levels of obstruction were the common canaliculus in 14 eyes (23.3%), the lacrimal sac in 13 eyes (21.7%), the duct-sac junction in 13 eyes (21.7%) and the nasolacrimal duct (NLD) in 20 eyes (33.3%). The ductsac junction obstruction was treated most successfully (100%), followed by NLD obstruction (90%), common canaliculus obstruction (78.6%) and saccal obstruction (69.2%). CONCLUSION: In patients with lacrimal drainage system obstruction, preoperative evaluation of obstruction level using DCG may be helpful for predicting the surgical outcome of endoscopic DCR. The saccal obstruction may have a worse prognosis than the other obstruction levels.

Myoepithelial Carcinoma Originated from the Maxillary Sinus / 대한이비인후과학회지

Myoepithelial carcinoma is a very rare malignant tumor accounting for less than one percent of the salivary gland neoplasms. This uncommom tumor, showing almost exclusively tumor cells with myoepithelial differentiation, is most commonly diagnosed in the parotid gland and in the minor silivary glands of the palate. We report a 77-year-old woman with myoepithelial carcinoma originating from maxillary sinus, one of the most unusual locations. The patient presented with progressive nasal obstruction and signs of a space-occupying lesion in the left maxillary sinus. A frozen biopsy identified a malignant tumor and a radical maxillectomy was performed. Histology confirmed the presence of a malignant myoepithelial carcinoma. Patient was followed up for one year without any recurrence or distant metastasis.

Delayed Reduction of Pure Medial Blowout Fracture of the Orbital Wall / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The timing of surgery is an important consideration point in the management of blowout fracture (BOF) of the orbit. This study aimed to compare the surgical outcome of early and delayed reduction and to suggest the best timing of surgery in the pure medial BOF of the orbit. SUBJECTS AND METHOD: Fifty-two patients who had endoscopic endonasal reduction of medial BOF were studied retrospectively. Patients were divided into an early group (N=42) who had surgery within one month after the trauma and a delayed group (N=10) who had surgery after one month from the trauma. Surgical indications, results of the surgery, and complications were compared between the two groups. RESULTS: The surgical indications in the early group were persistent diplopia, large defect expecting later enophthalmos and limitation of EOM, whereas the delayed group complained mainly of enophthalmos and diplopia. There were no significant differences in surgical outcomes and the rate of complications between the two groups. CONCLUSION: When patients with pure medial BOF have large defects without any persistent diplopia and limitation of EOM, surgery would be safely deferred until significant enophthalmos occurs.

Non-Functional Parathyroid Adenoma Presenting as a Massive Cervical Hematoma: A Case Report

Parathyroid adenoma usually manifests with symptoms related to hypercalcemia, such as urinary stone and bone fracture. It may also present with asymptomatic hypercalcemia. However, spontaneous cervical hematoma may occur very rarely as a result of extracapsular hemorrhage of a cervical parathyroid adenoma causing acute painful cervical swelling, bruising, dyspnea, hoarseness and dysphagia. We report a 44-year-old woman who manifested as a spontaneous cervical hematoma without any clinical evidence of hyperparathyroidism.