Inflammatory Endotypes of Chronic Rhinosinusitis in the Korean Population: Distinct Expression of Type 3 Inflammation.

PURPOSE: Cluster analyses on inflammatory markers of chronic rhinosinusitis (CRS) in Asians from multicenter data are lacking. This multicenter study aimed to identify the endotypes of CRS in Koreans and to evaluate the relationship between the endotypes and clinical parameters. METHODS: Nasal tissues were obtained from patients with CRS and controls who underwent surgery. The endotypes of CRS were investigated by measuring interleukin (IL)-5, interferon (IFN)-γ, IL-17A, IL-22, IL-1ß, IL-6, IL-8, matrix metalloproteinase-9, eotaxin-3, eosinophil cationic protein, myeloperoxidase (MPO), human neutrophil elastase (HNE), periostin, transforming growth factor-ß1, total immunoglobulin E (IgE), and staphylococcal enterotoxin (SE)-specific IgE. We performed hierarchical cluster analysis and evaluated the phenotype, comorbidities, and Lund-Mackay computed tomography (LM CT) score in each cluster. RESULTS: Five clusters and 3 endotypes were extracted from 244 CRS patients: cluster 1 had no upregulated mediators compared to the other clusters (mild mixed inflammatory CRS); clusters 2, 3, and 4 had higher concentrations of neutrophil-associated mediators including HNE, IL-8, IL-17A, and MPO (T3 CRS); and cluster 5 had higher levels of eosinophil-associated mediators (T2 CRS). SE-specific IgE was undetectable in T3 CRS and had low detectable levels (6.2%) even in T2 CRS. The CRS with nasal polyps (CRSwNP) phenotype and LM CT scores showed no significant differences between T2 and T3 CRS, while the incidence of comorbid asthma was higher in T2 CRS than T3 CRS. In T3 clusters, higher levels of neutrophilic markers were associated with disease severity and CRSwNP phenotype. CONCLUSIONS: In Koreans, there is a distinct T3 CRS endotype showing a high proportion of CRSwNP and severe disease extent, along with T2 CRS.

A Case of Massive Subcutaneous Emphysema and Pneumomediastinum Due to Dehiscence of Stoma After Emergent Tracheostomy.

Tracheostomy is commonly performed on patients who require long-term ventilator support. As with all other airway managements, tracheostomy comes with risks: tracheal scarring, tracheal rupture, pneumothorax, and tracheoesophageal fistula. Although rare, free air leakage into the surrounding tissues of the tracheostomy site and consequent pneumomediastinum can also occur due to various reasons, such as tracheal rupture and mispositioning of the tracheal tube. Such conditions may require treatments including high flow oxygen, ventilator management, and occasionally surgical intervention. In our case of a 61-year-old female, emergent tracheostomy was performed and subsequent complications of massive pneumomediastinum and subcutaneous emphysema were treated with negative pressure wound therapy. The follow-up radiograph after negative pressure wound therapy showed resolution of pneumomediastinum and subcutaneous emphysema, and there were no additional complications. Negative pressure wound therapy is an effective treatment option for massive pneumomediastinum and subcutaneous emphysema after tracheostomy.

Usefulness of combined handheld ultrasound and fluoroscopy-guided injection in adhesive capsulitis of the shoulder: A prospective, randomized single blind-pilot study.

BACKGROUND: Ultrasound is increasingly being utilized in the diagnosis and treatment of adhesive capsulitis. OBJECTIVE: To compare the therapeutic effects and advantages of combined handheld ultrasound and fluoroscopy-guided intra-articular corticosteroid injection with those of conventional ultrasound-guided corticosteroid injection in adhesive capsulitis of the shoulder. METHODS: A total of 39 patients diagnosed with adhesive capsulitis of the shoulder were randomly assigned into two groups. Group A patients (n= 19) underwent combined handheld ultrasound and fluoroscopy-guided corticosteroid injection and group B patients (n= 20) underwent conventional ultrasound-guided corticosteroid injection to the intra-articular space of the shoulder twice. Treatment efficacy was assessed at 2 and 6 weeks after the final injection, based on the verbal numeric pain scale, Shoulder Pain and Disability Index, and range of motion. Secondary outcome measures were the accuracy and procedure time. RESULTS: Both injection methods were effective in the treatment of adhesive capsulitis. No significant differences in treatment efficacy and injection accuracy were observed between the two groups (p> 0.05). CONCLUSIONS: This study showed no statistical differences in treatment efficacy between 2 groups. However, the combined use of ultrasound and fluoroscopy can increase the accuracy of injection compared with conventional ultrasound alone.

Unilateral sudden sensorineural hearing loss with vertigo as a first symptom of bilateral internal auditory canal metastases: a case report.

There have been relatively few reports of bilateral internal auditory canal metastases of asymptomatic primary pulmonary adenocarcinoma presenting as unilateral sudden sensorineural hearing loss and vertigo. We report a case of a 60-year-old male patient who complained of sudden hearing loss in the right ear and vertigo. Upon a physical examination, no definite neurological signs or nystagmus were observed. Pure-tone audiometry showed deafness in the right ear at all frequencies and high-frequency sensorineural hearing loss in the left ear. The video head impulse test suggested bilateral vestibulopathy. Magnetic resonance imaging of the brain (with gadolinium contrast) revealed bilateral internal auditory canal enhancement and a variable-sized nodular and peripheral-enhancing lesion in the cerebrum and the right cerebellum. A computed tomographic and bronchoscopic biopsy identified asymptomatic primary pulmonary adenocarcinoma in the left upper lobe of the lungs. This is a rare report of bilateral internal auditory canal metastases in an asymptomatic patient with primary pulmonary adenocarcinoma who initially presented with symptoms of unilateral sudden sensorineural hearing loss with vertigo.

Fluoroscopy-Guided Transforaminal versus Caudal Epidural Steroid Injection for Chronic Pain After Spinal Surgery: A Retrospective Mid-Term Comparative Study.

INTRODUCTION: This study is to compare advantages, safety and mid-term effects of fluoroscopy (FL)-guided transforaminal (TF) to caudal (CA) epidural steroid injection (ESI) for chronic pain after spinal surgery (CPSS) by assessing pain relief and improvement of functionality. METHODS: Patients with radicular pain in CPSS who received FL-guided CA (n = 21) or TF (n = 28) ESI were included in this retrospective study. Complication frequencies, adverse events, treatment effects, and functional improvements for each procedure were compared at 1, 3, and 6 months following the last injection. RESULTS: Both the Oswestry Disability Index (ODI) and verbal numeric pain scale scores (VNS) demonstrated improvement in both groups at all 1, 3, and 6 months following the last injection, without meaningful difference between groups (p < 0.05). Moreover, no meaningful difference was present between groups in terms of treatment success rate at every time point. The amount of time used for the injection procedure was shorter in CA group than in TF group (410.32 ± 25.73 seconds vs 640.65 ± 18.03 seconds, p < 0.05). Within 2 weeks of the injection treatment, the patient satisfactory scores were evaluated, with excellent being rated 85.7% (n = 18) among CA-ESI patients and 55.7% (n = 16) among TF-ESI patients (p < 0.05). Logistic regression analysis revealed that variables such as method of injection (CA or TF approach), sex, use of analgesics, pain duration, number of injections, and age were not significant variables for successful treatment results. There were no adverse complications after the procedure in both groups. CONCLUSION: The outcomes of FL-guided CA-ESI and TF-ESI for CPSS are similar in terms of pain reduction and functional improvements. CA-ESI is associated with lesser procedure time. In addition, compared with the TF-ESI, the patient experiences less discomfort during the injection, and the satisfaction with the injection treatment is confirmed to be better. Accordingly, both methods are effective; however, in the CA approach, patient satisfaction is higher and the procedure time is shorter.

Ultrasound-Guided Selective Nerve Root Block versus Fluoroscopy-Guided Interlaminar Epidural Block versus Fluoroscopy-Guided Transforaminal Epidural Block for the Treatment of Radicular Pain in the Lower Cervical Spine: A Retrospective Comparative Study.

Background: Recently, ultrasound- (US-) guided selective nerve root block (SNRB) has been reported to have similar effects compared to fluoroscopy- (FL-) guided cervical epidural steroid injection (CESI). There is no published study comparing the therapeutic efficacy and safety of interlaminar- (IL-) CESI and transforaminal- (TF-) CESI with US-guided SNRB. Our retrospective study aimed to compare the mid-term effects and advantages of the US-guided SNRB, FL-guided IL-CESI, and TF-CESI for radicular pain in the lower cervical spine through assessment of pain relief and functional improvement. Methods: Patients with radicular pain in the lower cervical spine who received guided SNRB (n = 44) or FL-guided IL (n = 41) or TF-CESI (n = 37) were included in this retrospective study. All procedures were performed using a FL or US. The complication frequencies during the procedures, adverse event, treatment effects, and functional improvement were compared at 1, 3, and 6 months after the last injection. Results: Both the Neck Disability Index (NDI) and Verbal Numeric Scale (VNS) scores showed improvements at 1, 3, and 6 months after the last injection in all groups, with no significant differences between groups (P < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), cause, sex, age, number of injections, and pain duration were not independent predictors of treatment success. Blood was aspirated before injection in 7% (n = 3), 14% (n = 6), and 0% patients in the FL-guided IL, TF, and US-guided groups, respectively. In 2 patients of FL-guided IL and 7 of FL-guided TF group, intravascular contrast spread was noted during injection. Conclusions: Our results suggest that, compared with FL-guided IL and TF-CESI, US-guided SNRB has a low intravascular injection rate; it is unlikely that serious complications will occur. Also, US-guided SNRB requires a shorter administration duration while providing similar pain relief and functional improvements. Therefore, for the treatment of patients with lower cervical radicular pain, US-guided SNRB should be considered as a prior epidural steroid injection.

Sarcomatoid carcinoma after radiotherapy for early-stage oral squamous cell carcinoma: Case report.

RATIONALE: Sarcomatoid carcinoma is a rare variant of squamous cell carcinoma (SCC) with poor prognosis. Previous radiation has been reported as one of the etiologic factors. PATIENT CONCERNS: We describe a case of a 57-year-old man presented with a painless mass in the left supraclavicular area. Five years before, he was diagnosed with SCC in floor of mouth (FOM) and underwent radiotherapy (RT). DIAGNOSES: Sonography-guided biopsy on the supraclavicular lymph node revealed diffuse spindle cell proliferation with a focus of squamous differentiation. Local recurrence on primary site or distant metastasis was not obvious on both computed tomography (CT) of the neck and F-fluorodeoxyglucose positron emission tomography CT. The final diagnosis was confirmed as sarcomatoid carcinoma via surgery. INTERVENTIONS: The patient underwent surgery including explorative resection of the mouth floor, excision of the submandibular gland, and modified radical neck dissection. Following surgery, the patient received adjuvant radiation therapy. OUTCOMES: There were no complications according to the surgery. Six months after adjuvant therapy, distant metastasis to liver was identified. The patient is currently undergoing palliative chemotherapy. LESSONS: This may be the first reported case of sarcomatoid carcinoma arising from early-stage SCC in FOM that was previously treated with RT alone. When RT is performed as a single modality for oral SCC, even in an early stage, rigorous follow-up should be performed.

Cerebellar infarction after posterior direct reduction and fixation to treat an unstable Jefferson fracture: a case report.

A 42-year-old man had an unstable Jefferson type IV atlas fracture with unilateral vertebral artery occlusion after a diving accident. We performed C1-ring reconstruction with a crosslink rod and C2 fixation to directly reduce the fracture fissure. Within 6 h, cerebellar hemisphere infarction developed. After decompressive craniectomy, duroplasty, and release of the vertebral artery occlusion caused by the transfixing rod, a postoperative computed tomography angiogram showed that blood flow in the right vertebral artery improved. We suggest cautiously inserting screws into the fractured C1 lateral mass and gently tightening the crosslink rod to prevent distal migration of a thrombus.

Middle Ear Barotrauma in Student Pilots.

INTRODUCTION: The present study reports the clinical features of middle ear barotrauma in student pilots in the Republic of Korea Air Force. METHODS: The authors reviewed medical records of student pilots with barotrauma. The grade of barotrauma was assigned using Teed's classification. This study included nasal symptoms, endoscopic findings of the nasal cavity, and clinical course (duration, recurrence). The relationship between middle ear barotrauma and the nasal airway was also evaluated. RESULTS: There were 57 cases in 51 pilots included. There were 49 cases (86.0%) that showed unilateral disease and 4 subjects experienced relapse. Two subjects (3.9%) had chronic rhinosinusitis and four subjects (7.8%) had allergic rhinitis. Ear fullness was reported in all cases, while hearing loss and persistent ear pain were reported in 3 cases (5.3%) and 19 cases (33.3%), respectively. Stuffy nose (26 cases, 45.6%) and rhinorrhea (24 cases, 42.1%) were relatively common. Most cases were Grade 0 (23 cases, 40.3%) or Grade III (27 cases, 47.4%) according to Teed's classification. Septal deviation was observed in 12 cases (21.0%), while turbinate hypertrophy was seen in 53 cases (93.0%) and increased nasal discharge in 33 cases (57.9%). The grade of barotrauma varied significantly according to the severity of turbinate hypertrophy and nasal discharge. The mean duration of disease was 6.8 d. DISCUSSION: Nasal symptoms and endoscopic findings showed some association with the grade and duration of barotrauma. Most cases resolved within a week; however, barotrauma showed persistence or relapse in some cases.Sohn JH, Cho KR. Middle ear barotrauma in student pilots. Aerosp Med Hum Perform. 2017; 88(4):406-412.

Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain: A retrospective comparative study.

The aim of this study was to compare the mid-term effects and benefits of ultrasound (US)-guided and fluoroscopy (FL)-guided medial branch blocks (MBBs) for chronic lower lumbar facet joint pain through pain relief, functional improvement, and injection efficiency evaluation.Patients with chronic lumbar facet joint pain who received US (n = 68) or FL-guided MBBs (n = 78) were included in this retrospective study. All procedures were performed under FL or US guidance. Complication frequency, therapeutic effects, functional improvement, and the injection efficiency of MBBs were compared at 1, 3, and 6 months after the last injection.Both the Oswestry Disability Index (ODI) and the verbal numeric pain scale (VNS) improved at 1, 3, and 6 months after the last injections in both groups. Statistical differences were not observed in ODI and VNS between the groups (P > .05). The proportion of patients who reported successful treatment outcomes showed no significant differences between the groups at different time points. Logistic regression analysis showed that sex, pain duration, injection methods, number of injections, analgesic use, and age were not independent predictors of a successful outcome. US guidance was associated with a significantly shorter performance time.US-guided MBBs did not show significant differences in analgesic effect and functional improvement compared with the FL-guided approach. Therefore, by considering our data from this retrospective study, US-guided MBBs warrant consideration in the conservative management of lower lumbar facet joint pain.

Epithelial-myoepithelial carcinoma of the nasopharynx: A case report and review of the literature.

An 80-year-old female with complaints of right-sided nose blockage and occasional epistaxis for several months was referred to Sanggye Paik Hospital (Seoul, Korea). Nasal examination revealed a hemorrhagic mass protruding towards the right posterior nasal cavity, for which the patient was subjected to excisional biopsy. The pathological diagnosis was epithelial-myoepithelial carcinoma, as immunohistochemical analysis revealed that the inner cells stained positive for cytokeratin 7, an epithelial cell marker, whereas the outer cells stained positive for smooth muscle actin and P63, consistent with a myoepithelial phenotype. The patient received concurrent chemoradiation therapy followed by systemic chemotherapy. Following the achievement of a partial response, the patient's treatment course was uneventful. Follow-up at 24 months revealed a stable status at partial response, with no subsequent progression.

Comparison of ultrasound (US)-guided intra-articular injections by in-plain and out-of-plain on medial portal of the knee.

To compare the accuracy rates between ultrasound (US)-guided in-plain (IP), out-of-plain (OOP) and blind knee intra-articular (IA) injection via the mid-medial portal. US-guided IA injection in the IP, OOP, and blind methods was performed on 126 knees with radiographically confirmed knee osteoarthritis (Kellgren-Lawrence grade 2 or 3) without effusion. About 6 ml of a mixed material containing 1% lidocaine (1 mL) and triamcinolone 20 mg (1 mL) and nonionic contrast (4 mL) was injected into the IA space of the knee through the mid-medial portals. After an US-guided and blind IA injection into the knee joint, a radiographic image was taken to determine whether the injected material had reached the IA space or infiltrated into the soft tissue. US-guided IA injections in the IP (97%; P < 0.05) and OOP method (95%; P < 0.05) showed significantly higher accuracy rate than injections in the blind injection (78%). Both US-guided IA injection methods may be used to access the knee joint with high degree of accuracy.

Congenital primary cholesteatoma of external auditory canal.

A 2-year-old female child is reported with congenital cholesteatoma of the right external auditory canal. We describe the clinical features, computed tomography finding and surgical treatment. Congenital cholesteatomas can occur within the temporal bone. Congenital cholesteatoma of the external auditory canal is rare. Generally, it appears in the canal floor. Treatment consists of the resolution of granulation and removal of debris.

Balloon catheter assisted excision of benign cervical cyst.

OBJECTIVES: Benign cystic masses that develop in the neck are easily excised with a wide skin incision. However, if the cyst is perforated and the contour of the cyst is not maintained during surgery, complete excision may be difficult. We developed a surgical method that can maintain the contour of a cyst and decrease the wound size with a balloon catheter. METHODS: Two cases with a branchial cleft cyst (BCC) were removed using this method without recurrence. The surgical technique includes a skin incision above the cyst, and fine dissection to expose the cyst wall. Then a small tap incision was created on the cyst using a #11 blade and a #14 Fr. Foley catheter was inserted through the incision site and the balloon was inflated up to 4 cm(3) using normal saline. The fluid inner content was carefully removed keeping the intracystic balloon inflated. By pulling and releasing the catheter, the cyst was dissected carefully and excised. RESULTS: Complete excision of the cyst was performed with the balloon catheter successfully. The final pathological diagnosis was BCC in the two cases. CONCLUSIONS: The balloon-assisted technique was easy to perform and could be used for the excision of a benign cystic neck mass.