Occult lymph node metastasis and risk of regional recurrence in papillary thyroid cancer after bilateral prophylactic central neck dissection: A multi-institutional study.

BACKGROUND: The impact of occult lymph node metastasis on regional recurrence after prophylactic central neck dissection for preoperative, nodal-negative papillary thyroid cancer is controversial. We investigated risk factors for regional lymph node recurrence in papillary thyroid cancer patients who underwent total thyroidectomy and bilateral prophylactic central neck dissection. Analysis was according to clinicopathologic characteristics and occult lymph node metastasis patterns. METHODS: This multicenter study enrolled 211 consecutive patients who underwent total thyroidectomy with bilateral prophylactic central neck dissection for papillary thyroid cancer without evidence of central lymph node metastasis on preoperative imaging. Clinicopathologic features and central lymph node metastasis patterns were analyzed for predicting regional recurrence. Multivariate Cox regression analysis was used to identify independent factors for recurrence. RESULTS: Median follow-up time was 43 months (24-95 months). Ten patients (4.7%) showed regional lymph node recurrence. The estimated 5-year, regional recurrence-free survival was 95.2%. Tumor size ≥1 cm, central lymph node metastasis, lymph node ratio, and prelaryngeal lymph node metastasis were associated with regional recurrence in univariate analysis (P < .05). In multivariate analysis, a lymph node ratio ≥ 0.26 was a significant risk factor for regional lymph node recurrence (odds ratio = 11.63, P = .003). Lymph node ratio ≥ 0.26 was an independent predictor of worse recurrence-free survival on Cox regression analysis (hazard ratio = 11.49, P = .002). CONCLUSION: Although no significant association was observed between the presence of occult lymph node metastasis and regional recurrence, lymph node ratio ≥ 0.26 was an independent predictor of regional lymph node recurrence in papillary thyroid cancer patients who underwent total thyroidectomy and bilateral prophylactic central neck dissection.

Optimal timing of saliva collection to detect pepsin in patients with laryngopharyngeal reflux.

OBJECTIVES/HYPOTHESIS: To determine salivary pepsin levels as a function of collection time. STUDY DESIGN: A prospective, case-control study. METHODS: We selected 57 patients with clinical symptoms and signs of laryngopharyngeal reflux who underwent 24-hour multichannel intraluminal impedance-pH (24h MII-pH) monitoring tests, and 12 control subjects without clinical symptoms and signs of laryngopharyngeal reflux. All subjects were instructed to collect saliva samples upon waking, 1 hour after each meal (3 times per day), and upon any occurrence of laryngopharyngeal reflux (LPR) symptoms. The pepsin levels in saliva were measured by using enzyme-linked immunosorbent assay. The Reflux Symptom Index survey was also administered. RESULTS: A total of 50 patients in whom LPR was diagnosed based on results of 24h MII-pH monitoring test were enrolled in the study. The average pepsin level upon waking was 17.2 ng/mL, which was significantly higher than that measured in samples collected at any other time (P < .005). Pepsin levels were higher in patients with LPR than those in controls. The Reflux Symptom Index scores were statistically different between these groups of subjects. CONCLUSIONS: The levels of total pepsin in saliva collected upon waking were significantly higher in the group of patients presenting with LPR symptoms and who demonstrated at least one episode of proximal esophageal reflux during 24h MII-pH monitoring. Furthermore, the average pepsin level upon waking was higher than that measured at any other time. Measuring pepsin levels in the saliva upon waking may be a useful method in the diagnosis of LPR. LEVEL OF EVIDENCE: 3b Laryngoscope, 126:2770-2773, 2016.

Clinicopathologic characteristics and pattern of central lymph node metastasis in papillary thyroid cancer located in the isthmus.

OBJECTIVES/HYPOTHESIS: The aim of this study was to evaluate the clinicopathologic characteristics and pattern of lymph node (LN) metastasis in papillary thyroid cancer (PTC) located in the isthmus. STUDY DESIGN: Retrospective cohort study. METHODS: One hundred ninety consecutive patients with PTC who underwent total thyroidectomy and bilateral central neck dissection were analyzed. Preoperative ultrasonography was reviewed to identify PTC located in the isthmus. Clinicopathologic factors including age, sex, tumor size, extrathyroidal extension (ETE), margin, angiolymphatic invasion, and nodal metastasis were evaluated. RESULTS: Of 190 PTC patients, 14 patients (7.3%) had a tumor located in the isthmus. The PTCs located in the isthmus were more likely to have ETE and central LN involvement. Furthermore, PTCs located in the isthmus had a higher frequency of metastasis to pretracheal and prelaryngeal LNs than those located in the lobes. CONCLUSION: PTCs located in the isthmus were associated with ETE and more likely to involve the pretracheal and prelaryngeal LNs. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:2419-2421, 2016.

Audiologic evaluation of vestibular schwannoma and other cerebellopontine angle tumors.

CONCLUSION: Otologic accompanying symptoms, audiogram patterns, and hearing levels according to tumor size differed in patients with CPA tumors classified as VS and non-VS types. OBJECTIVES: The diagnosis of CPA tumors is often delayed. Late-diagnosed tumors can grow until they compress and damage vital structures. This study evaluated the otologic symptoms and results of audiologic tests in patients with vestibular schwannomas (VS) and other types of CPA tumors. METHODS: This study included 171 patients with otologic symptoms who were diagnosed with CPA tumors, including 116 with VS and 55 with other types of CPA tumors. Factors analyzed retrospectively included tumor type, size, and location and the results of audiometric examinations. RESULTS: The most common chief complaint in patients diagnosed with CPA tumors was asymmetrical hearing loss, with most frequent accompanying symptoms being tinnitus in patients with VS and dizziness in those with other types of CPA tumor. The most frequent patterns of hearing loss were the descending type in patients with VS and the flat type in patients with non-VS tumors (p < 0.05). Pure tone thresholds tended to increase more in patients with VS than non-VS tumors according to tumor size, and pure tone averages were significantly higher in patients with VS than non-VS tumors of 11-25 mm in size (p < 0.05).

Otologic manifestations of acoustic neuroma.

CONCLUSION: Many patients with acoustic neuroma (AN) experience hearing loss and tinnitus. Time from first symptoms to diagnosis can be considerable. AN should be suspected, and MRI scans performed, in patients with hearing loss accompanied by asymmetry, tinnitus, low speech discrimination score (SDS), and abnormal auditory brainstem response (ABR). OBJECTIVES: To determine the otorhinolaryngological factors associated with AN by analyzing the clinical manifestations and diagnostic test results of patients with AN before MRI scanning. METHODS: This study enrolled 114 patients definitively diagnosed with AN after visiting the Ear-Nose-and-Throat and Neurosurgery Departments of Kyung Hee University Medical Center from 2001 to 2013. Factors retrospectively analyzed included patient age, gender, major symptoms, accompanying symptoms, symptom duration, pure-tone audiometry, SDS, asymmetry, tinnitogram, ABR, and MRI scan results. RESULTS: The main symptom of AN was hearing loss, and the most frequent accompanying symptom was tinnitus. More severe deafness correlated significantly with lower SDS (p < 0.05). Asymmetric hearing was observed in 75 of 116 patients (64.6%), and mean SDS was 73.1 ± 34.1%. Of patients with latencies of waves I, III, and V on ABR tests, 56.1%, 92.4%, and 92.4%, had interaural latency differences ≥0.2 ms. However, audiometry results did not correlate with lesion site or tumor size (p > 0.05).

Comparison of sudden deafness in adults and children.

OBJECTIVES: Although many studies have assessed sudden deafness in adults, sudden deafness has not been evaluated in children. We therefore evaluated the differences in sudden deafness between children and adults. METHODS: We compared clinical manifestations, including gender, audiogram pattern of initial hearing loss, and recovery rate after treatment in 87 children and 707 adults diagnosed with sudden deafness from September 2003 and August 2012. RESULTS: There were no differences in sex, side, or audiogram between children and adults (P>0.05 each). Hearing recovery rates in children and adults were 72.4% and 70.6%, respectively (P>0.05). Both children and adults with mild hearing loss showed significantly greater hearing recovery rates than individuals with profound hearing loss (P<0.05 each). The percentage with initially mild and moderate hearing loss was higher in children than in adults, as were the recovery rates of children compared to adults with initially mild, moderate-severe, and profound hearing loss (P<0.05 each). In regard to final hearing outcome after treatment, a low percentage of children showed no improvement whereas a high percentage showed complete recovery; a higher percentage of children than of adults showed complete recovery (P<0.05). Recovery rate from profound hearing loss was significantly higher in children than in adults (60.0% vs. 45.4%, P<0.05). CONCLUSION: Degree of hearing loss, gender, side, and recovery rate were similar in children and adults, but the rate of complete recovery was higher in children.

Changing patterns of bacterial strains in adults and children with otitis media in korean tertiary care centers.

OBJECTIVES: Otitis media (OM) is an infectious disease that affects all age brackets. Aural discharge is a typical symptom, occurring in all subtypes of OM. We have compared the identity and antibiotic sensitivity of bacteria isolated from aural discharges of adults and children with various types of OM, including acute OM (AOM), OM with effusion (OME), chronic OM (COM), and cholesteatomatous OM (CSOM). METHODS: The study involved 2,833 patients who visited five tertiary hospitals between January 2001 and December 2010 and were diagnosed with AOM, OME, COM, or CSOM. The patients were divided into a pediatric group and an adult group, and the distribution of cultured bacteria and their antibiotic sensitivity were compared in the two groups. RESULTS: Bacterial detection rates were higher in adults than in children with OME and COM (P=0.000 each). The majority of the bacteria cultured from patients with AOM and OME bacteria were methicillin-susceptible Staphylococcus aureus (MSSA) and Streptococcus pneumoniae. Bacteria cultured from children were more susceptible to antibiotics (P=0.002) and had higher antibiotic sensitivity (P=0.001) than were bacteria cultured from adults. The majority of bacteria culture from patients with COM and CSOM were MSSA and pathogenic Pseudomonas aeruginosa. The frequency of methicillin-resistant Staphylococcus aureus was significantly higher in adults than in children, and more strains of bacteria isolated from adults were sensitive to the antibiotics septrin, vancomycin, and teicoplanin. CONCLUSION: Bacteria cultured from children were more susceptible to antibiotics and had higher antibiotic sensitivity than did bacteria cultured from adults.

Agreement between the Facial Nerve Grading System 2.0 and the House-Brackmann Grading System in Patients with Bell Palsy.

OBJECTIVES: We have analyzed the correlation between the House-Brackmann (HB) scale and Facial Nerve Grading System 2.0 (FNGS 2.0) in patients with Bell palsy, and evaluated the usefulness of the new grading system. METHODS: Sixty patients diagnosed with Bell palsy from May 2009 to December 2010 were evaluated using the HB scale and FNGS 2.0 scale during their initial visit, and after 3 and 6 weeks and 3 months. RESULTS: The overall intraclass correlation coefficient (ICC) was 0.908 (P=0.000) and the Spearman correlation coefficient (SCC) was 0.912 (P<0.05). ICC and SCC displayed differences over time, being 0.604 and 0.626, respectively, at first visit; 0.834 and 0.843, respectively, after 3 weeks; 0.844 and 0.848, respectively, after 6 weeks; and 0.808 and 0.793, respectively, after 3 months. There was a significant difference in full recovery, depending on the scale used (HB, P=0.000; FNGS 2.0, P<0.05). The exact agreements between regional assessment and FNGS 2.0 for the mouth, eyes, and brow were 72%, 63%, and 52%, respectively. CONCLUSION: FNGS 2.0 shows moderate agreement with HB grading. Regional assessment, rather than HB grading, yields stricter evaluation, resulting in better prognosis and determination of grade.

Iron plays a certain role in patterned hair loss.

Role of iron in hair loss is not clear yet. The purpose of this study was to evaluate the relationship between iron and hair loss. Retrospective chart review was conducted on patients with female pattern hair loss (FPHL) and male pattern hair loss (MPHL). All patients underwent screening including serum ferritin, iron, and total iron binding capacity (TIBC), CBC, ESR and thyroid function test. For normal healthy controls, age-sex matched subjects who had visited the hospital for a check-up with no serious disease were selected. A total 210 patients with FPHL (n = 113) and MPHL (n = 97) with 210 healthy controls were analyzed. Serum ferritin concentration (FC) was lower in patients with FPHL (49.27 ± 55.8 µg/L), compared with normal healthy women (77.89 ± 48.32 µg/L) (P < 0.001). Premenopausal FPHL patients turned out to show much lower serum ferritin than age/sex-matched controls (P < 0.001). Among MPHL patients, 22.7% of them showed serum FC lower than 70 µg/L, while no one had serum FC lower 70 µg/L in healthy age matched males. These results suggest that iron may play a certain role especially in premenopausal FPHL. The initial screening of iron status could be of help for hair loss patients.

Better clinical results with long term benefits in melasma patients.

BACKGROUND: Low fluence Q-switched Nd:YAG laser has become popular in the treatment of melasma in Asian patients. However, it needs a lot of treatment sessions for substantial results and repetitive laser exposures may end up with unwanted depigmentation. OBJECTIVE: We evaluated clinical effects and safety of combinational treatment using intense pulsed light and low fluence Q-switched Nd:YAG laser over laser treatment alone. METHODS: Retrospective case series of 35 female patients with mixed type melasma were analyzed. Group A were treated with combination methods and group B with laser alone. At each visit, digital photographs were taken. Erythema index (EI) and melanin index (MI) were measured on the highest point on cheekbones. Modified melasma area and severity index (MASI) scores were marked using photographs by two blinded investigators. RESULTS: The mean values of MI and EI decreased significantly in both groups. Modified MASI score reduction were 59.35% and 45.66% in groups A and B, respectively. In group A, 12 out of 20 patients were followed up (mean 5.9 months) without any further treatments and no clinical aggravations were observed. All patients in group B required at least five more treatment sessions for satisfactory results. CONCLUSION: Combination treatment may provide more rapid clinical resolution in mixed type melasma with possible long term clinical benefits.

Intense Pulsed Light and Low-Fluence Q-Switched Nd:YAG Laser Treatment in Melasma Patients.

BACKGROUND: Recently, low fluence collimated Q-switched (QS) Nd:YAG laser has drawn attention for the treatment of melasma. However, it needs a lot of treatment sessions for the substantial results and repetitive laser exposures may end up with unwanted depigmentation. OBJECTIVE: We evaluated the clinical effects and safety of the combinational treatment, using intense pulsed light (IPL) and low fluence QS Nd:YAG laser. METHODS: Retrospective case series of 20 female patients, with mixed type melasma, were analyzed using medical records. They were treated with IPL one time, and 4 times of weekly successive low fluence Nd:YAG laser treatments. At each visit, digital photographs were taken under the same condition. Melanin index (MI) and erythema index (EI) were measured on the highest point on the cheekbones. Modified melasma area and severity index (MASI) scores were calculated by two investigators using digital photographs. RESULTS: The mean values of MI and EI decreased significantly after treatments. The modified MASI score has decreased by 59.35%, on average. Sixty percents of the participants did not require any more treatments, and no clinical aggravations were observed during the follow-up period (mean 5.9 months). CONCLUSION: IPL and low fluence laser may elicit a clinical resolution in the mixed type melasma with long term benefits.

Pigmentation above the constitutive level: an indicator of excimer laser radiation-induced erythema in Koreans.

Ultraviolet (UV) irradiation induces skin erythema, but it is not clear which factors have the greatest effects on UV sensitivity. Six healthy Korean adult men were enrolled and their melanin index (MI) and increment of erythema index (ΔEI) were measured. In each individual, 12 different sites were selected and 36 spots were irradiated with a single shot of monochromatic excimer laser with a dose of 350 mJ/cm(2) . The sites were categorized into three groups based on the cumulative sun exposure: UZ, unexposed zones; FEZ, frequently exposed zones; and IEZ, intermittently exposed zones. The sun exposure indexes (SEI) were also calculated based on previously described methods. ΔEI, MI and SEI were measured and calculated. The ΔEI of UZ was significantly higher than that of FEZ, but lower than that of IEZ. In general, there was a significant relationship between ΔEI and MI (R(2) = 0.135). However, IEZ did not show significant results. In contrast, there was a stronger relationship between ΔEI and SEI (R(2) = 0.344). Overall, the values were significantly higher for the SEI (0.541 [UZ], 0.281 [IEZ] and 0.228 [FEZ]) than for MI (0.311 [UZ], 0.011 [IEZ] and 0.073 [FEZ]). There were significant site variations in UV sensitivity along with skin pigmentation. In addition, significant differences were observed according to the exposure frequency. The SEI was found to be strongly correlated with UV sensitivity. These results suggest that the induced level of pigmentation above the constitutive level will be a better indicator for UV sensitivity than baseline MI.

Effects of murine dermal cells on the regulation of hair growth is dependent on the cell number and post-natal age of newborn mice.

Dermal cells from neonatal mice can initiate the formation of hair follicles (HFs) when combined with adult mouse epidermal cells and transplanted subcutaneously into athymic mice. In the present study, the effects of dermal cells on HF formation were tested in terms of total cell number and the time course of cell harvest. Results demonstrated that the number of dermal cells is critical to the formation of HF. Furthermore, hair forming ability is rapidly decreasing as the neonatal mice age. To examine potential differences in gene expression, cDNA array was performed. Results demonstrate that numerous molecules which are directly involved in receptor and signaling correlated with decreased hair inductivity in early time points after delivery. It is reported that bone morphogenic protein (BMP)-6 and Wnt3a treatment increased hair inductivity of dermal papilla cells. But in our study, no changes were observed in the expression levels of BMP-6 and Wnt3a. However, several Wnt related genes demonstrate increased or decreased expression levels. Thus, our results suggest that co-ordinated regulation of these molecules will be important in hair neogenesis within our model system.

Low level light could work on skin inflammatory disease: a case report on refractory acrodermatitis continua.

Low level laser or light treatment on the various clinical condition is getting considerable attention now. However, there has been no report about the clinical effect of low level polarized polychromatic noncoherent light (LPPL) on the inflammatory skin disease. We experienced a case of acrodermatitis continua in a pregnant woman refractory to any conventional treatment including the most potent topical steroid. She was successfully treated with LPPL. LPPL could be a possible treatment modality producing substantial clinical result in inflammatory skin condition without any side-effect.

Unilateral psoriasis in a woman with ipsilateral post-mastectomy lymphedema.

Psoriasis is a multi-factorial disease with various clinical manifestations. We present a case of unilateral psoriasis associated with ipsilateral lymphedema that developed after mastectomy for breast cancer. A 42-year-old Korean woman was referred to our clinic with a 1-month history of multiple erythematous scaly patches on the right arm, back, and breast and was diagnosed with psoriasis by a skin biopsy. Three years previously, she had been diagnosed with breast cancer (T1N2), underwent a right quadrantectomy and axillary lymph node dissection, and completed adjuvant chemotherapy followed by high-dose adjuvant radiotherapy. She had started rehabilitation therapy on the right arm for secondary lymphedema 30 months previously. Because of the long interval between radiation and psoriasis, we speculated that changes in the local milieu caused by the lymphedema might be a causative factor. We hereby report a rare case of unilateral psoriasis following post-mastectomy lymphedema.

Penicillamine-induced Elastosis Perforans Serpiginosa and Cutis Laxa in a Patient with Wilson's Disease.

Elastosis perforans serpiginosa (EPS) is a rare reactive perforating dermatosis that is characterized by the transepidermal elimination of abnormal elastic fibers. Penicillamine, which is one of the clear triggers for EPS, is a heavy metal chelator that is primarily used for disorders such as cystinuria and Wilson's disease. It may cause alterations in the dermal elastic tissue such as pseudo-pseudoxanthoma elasticum, acquired cutis laxa, EPS and anetoderma. Herein we present a case of cutis laxa and EPS in a 34-year-old man who was previously on a long-term, high-dose of penicillamine for Wilson's disease. The combination of EPS and cutis laxa induced by penicillamine has rarely been reported and we report the first such case in Korea.

Two cases of palmoplantar lichen planus with various clinical features.

Two cases of palmoplantar lichen planus with various clinical features. Palmoplantar lichen planus is a rare, localized variant of lichen planus. Although several clinical features of palmoplantar lichen planus may be seen, the erythematous scaly form is most common. We present two cases of palmoplantar lichen planus that show vesicle-like and petechia-like features, which are uncommon variants of palmoplantar lichen planus.