A Practical and Clinical Application of the Septoplasty / 대한이비인후과학회지

A nasal septal deviation is a condition that should be handled as a disease entity only when a patient complaints intractable nasal stuffiness or decreased quality of life. Also a surgeon should diagnose a various cause of the nasal obstruction including static and dynamic collapse of the nasal valve. Although septoplasty is most commonly performed operation to relieve the nasal obstruction, it is sometimes very difficult and cumbersome because of a variety of septal pathology. A surgeon should be aware of the specific condition of patients and should apply the tailored techniques to correct each condition. This review could provide a detailed and practical information at each steps of the septoplasty, also gives various tips to remind at the operation room and outpatient clinic. Recent papers regarding septoplasty techniques, tips and pearls, complications are reviewed and my personal recommendations with tiny tips are provided also.

The Footplate Suture Technique for External Nasal Valve Surgery

BACKGROUND AND OBJECTIVES: To report the preliminary results of the footplate suture technique for narrowing the columellar base to improve nasal respiration and the cosmetic features of the nasal sill. MATERIALS AND METHODS: Patients with nasal obstruction who presented with external nasal valve obstruction were treated with the footplate suture technique. Data on the patient characteristics, operative procedures, and outcomes were gathered from medical records. RESULTS: Five patients were included in this study. The footplate suture technique was used in all patients, together with septoplasty, batten graft and inferior turbinoplasty to improve the nasal valve obstruction as needed. In each case, divergent footplate segments of the medial nasal alar crura were identified and tied to medialize and narrow the columellar base. All patients had satisfactory subjective nasal breathing and cosmetic results. CONCLUSIONS: The footplate suture technique is an adjunctive procedure that improves the nasal obstruction and nasal sill disfiguration caused by external nasal valve obstruction, especially due to the divergent footplate segments of the medial alar crura.

A Case of Takotsubo Cardiomyopathy due to Submucosal Epinephrine Injection during Endoscopic Sinus Surgery / 대한이비인후과학회지

Epinephrine is widely used for hemostasis during endoscopic sinus surgery performed under local and general anesthesia. However, topical epinephrine can cause many adverse effects, such as hypertension, ventricular tachycardia, pulmonary edema and cardiac arrest. Takotsubo cardiomyopathy is a newly described clinical entity characterized by transient left ventricular dysfunction and no significant coronary artery stenosis. We experienced a rare case of reversible Takotsubo cardiomyopathy in a 56-year-old male after submucosal epinephrine injection with an appropriate dose during an endoscopic sinus surgery.

The Clinical Course and Prognostic Factors to Medical Treatment of Graves' Disease in Children and Adolescents

PURPOSE: The aim of this study was to observe clinical course including remission rate during antithyroid medication for Graves' disease in children and adolescents, and to evaluate factors related to remission. METHODS: This is a retrospective study of 42 patients (8 males), who were diagnosed at pediatric endocrine clinic in Chungbuk National University Hospital from January 1994 to December 2009. They were treated with antithyroid drugs only and were followed for at least 2 years. Their average age at diagnosis was 11.5 +/- 3.4 years, and average follow-up period was 4.5 +/- 2.2 years. RESULTS: At diagnosis, 64.3% of the subjects were in puberty, 87.8% showed goiter which was significantly prevalent in females (P < 0.05), and 38.9% manifested exophthalmos. Thyrotropin receptor antibody was positive in all the patients, whereas anti-microsomal antibody was positive in 88.1% and anti-thyroglobulin antibody in 81.0%. Twenty two (52.4%) patients remitted with 4.3 +/- 2.5 years' medication, and the others were continuously medicated at the last follow-up of 4.8 +/- 1.8 years. By quartile estimate for the remission time, 25 percentile was remitted at 3.7 years, 50 percentile at 7.1 years, and 75 percentile at 9.2 years. Among the factors for the remission, initial thyroid stimulating hormone level was significantly lower in non-remission group compared to remission group (P < 0.05). CONCLUSION: In pediatric Graves' disease treated only antithyroid drugs, the time required for remission is so long that it is necessary to establish fixed medication period and to choose definitive treatment modality as in adult Graves' disease through multicenter clinical study.

Two Cases of Congenital Vallecular Cyst with Respiratory Distress and Feeding Problems in Young Infant / 대한이비인후과학회지

Congenital vallecular cyst (VC) is a rare cause of stridor and respiratory distress in neonates and infants. Due to the anatomical location of the cyst, an infant with a VC is at risk of life-threatening upper airway obstruction and eventual death. The cyst sits in the vallecular space and can cause significant retroflexion of the epiglottis. It may also present with feeding problems resulting in failure to grow. Endoscopic laryngoscopy is necessary to visualize it and mar-supialization of the cyst is the preferred treatment. We present 2 successfully treated cases of congenital VC in young infants with symptoms of upper respiratory obstruction and feeding problems.

A Case of Bilateral Nasolabial Cysts / 대한이비인후과학회지

Nasolabial cyst is a rare non-odontogenic, developmental cyst that occurs in sublabial and premaxillary area. This cyst is usually unilateral, but it occurs bilaterally about 10% of cases. A 55-year-old woman visited our clinic with asymptomatic bilateral nasolabial swelling. Evaluation of history, physical examination and CT scan led to the diagnosis of a nasolabial cyst, and surgical excision was performed via sublabial approach. In intraoperative finding, two nasolabial cysts of similar size that entirely divided by anterior nasal spine were identified. The pathologic findings were consistent with nasolabial cysts. We herein report a rare case of bilateral occurrence of nasolabial cysts with a review of literatures.

A Case of Nasopharyngeal Papillary Adenocarcinoma: Nasal Endoscopic Approach / 대한이비인후과학회지

Low-grade nasopharyngeal papillary adenocarcinoma is an unusual nasopharyngeal tumor. This malignant tumor originates in the epithelium and exhibits adenocarcinomatous differentiation and indolent behavior. Macroscopically, these tumors are pedunculated polypoid masses that arise on the roof of the nasopharynx. Microscopically, they are characterized by papillary and glandular epithelial proliferation. We report a case of a 25-year-old woman who presented with a papillary adenocarcinoma on the roof of nasopharynx; in describing the case, we have focused on the histological features and endoscopic management of the tumor. The tumor was completely excised via nasal endoscopic approach. Immunohistochemical analysis of the tumor was performed based on a differential diagnosis of metastatic papillary thyroid carcinoma. The testing involved thyroid transcription factor-1, thyroglobulin, and epithelial membrane antigen analysis. The patient remained disease-free for over 6 months after the surgical excision performed via nasal endoscopic approach.

A Case of Schwannoma of the Nasal Septum / 대한이비인후과학회지

Schwannoma is a benign tumor originating from the peripheral nerve sheath that can arise on any myelinated nerve. A 32-year-old woman visited our clinic presenting with unilateral nasal obstruction. Based on the physical examination and CT scan, we initially diagnosed the disease as vascular origin tumor. Endoscopic excision was done after preoperative angiogram with embolization. Biopsy results revealed schwannoma originating from the nasal septum. Nasal septal schwannoma is extremely rare, and we herein report such a case with a review of literatures.

Association between the Total Homocysteine Concentration and the Bone Marrow Density and Bone Turnover Rate in Postmenopausal Women / 대한폐경학회지

OBJECTIVES: Hyperhomocysteinemia is related to fractures in the elderlies. We assessed the relationship between serum homocysteine and bone mass, size, and bone turnover rate. METHODS: This study included 2,670 postmenopausal women who underwent periodic health examinations in Ajou University Health Promotion Center, between January 2002 and December 2003. Serum homocysteine, bone turnover markers and bone mineral density were measured RESULTS: Patient age, osteocalcin, 25-vit D, total lumbar BMD, total lumbar T-score, the lowest lumbar BMD, the lowest lumbar T-score, femur neck BMD, femur neck T-score, femur trochanteric BMD and femur trochanteric T-score showed a significant correlation with the serum total homocysteine. However, after adjusting for age, the only osteocalcin was significantly correlated with the serum total homocysteine, At the 3rd lumbar vertebra, the BMC, volumetric BMD and areal BMD had a significant correlation with the serum total homocysteine but the bony size and the volume were not significant. After adjusting for age, the 3rd lumbar BMD was significantly correlated with the serum total homocysteine. CONCLUSION: Serum homocysteine level is correlated significantly with bone turnover rate, less with bone mass but not with bone size.

The Preliminary Research for Making Judgment on Not Guilty by Reason of Insanity and Guilty but Mentally Ill / 대한법의학회지

BACK GROUND: Our object is to conduct a questionnaire research with psychiatrists who have the experience of mental examination to suggest judgment standard for Not Guilty by Reason of Insanity and Guilty But Mentally Ill(diminished capacity). In addition, this study is expected to reduce the gap between the judgments on Not Guilty by Reason of Insanity and Guilty But Mentally Ill. METHODS: In making judgment on Not Guilty by Reason of Insanity and Guilty But Mentally Ill by experts, the questionnaire research is conducted through e-mail on the judgment standard on each mental disorders. According to the definition of mental disability, the item that shows higher percentage than the items of cognitional ability and volitional ability is considered as the requirement for judging mental disability. RESULTS: In all of 7 major mental disorders and disease groups, the symptoms and characteristics of the disease and the range of the influence of the symptom on the case were higher in 2-4 times than the induced standard (cognitional ability and volitional ability) from the legal and academic definitions of mental disability. CONCLUSIONS: The criteria for judging normal or mental disability is the cognitional ability and volitional ability. The criteria for judging Not Guilty by Reason of Insanity and Guilty But Mentally Ill in mental disability is the symptom and characteristics of the disease and the range of the influence of the symptom on the case.

Cephalometric differences in obstructive sleep apnea between obese and non-obese Korean male patients / 대한치과교정학회지

OBJECTIVE: The purpose of this study was to compare the cephalometric measurements of obese and non-obese Korean male patients with obstructive sleep apnea syndrome (OSA). METHODS: Eighty-seven adults who had visited the Sleep Disorder Clinic Center in Keimyung University, Daegu, Korea were examined and evaluated with polysomnography (PSG) and lateral cephalogram. They were divided into 4 groups (non-obese simple snorers, obese simple snorers, non-obese OSA patients, obese OSA patients) according to AHI (Apnea-Hypopnea Index) and BMI (Body Mass Index). RESULTS: The obese OSA group had the highest AHI among the 4 groups. The non-obese OSA group had a significantly steeper mandibular angle and shorter tongue length than the obese OSA group. The hyoid bone of the obese OSA group was positioned anterior and inferior as compared with the non-obese OSA group. Multiple regression analysis showed that tongue length in the obese OSA group and retroposition of hyoid bone in the non-obese OSA group were significant determinants for the severity of AHI. CONCLUSIONS: From a cephalometric point of view, the obese and non-obese pateints with OSA may be characterized by different pathogeneses. Therefore, they have to be managed by individualized treatment. For the obese OSA patients, weight control must be advised as a first choice and for the non-obese OSA patients, oral appliance, nasal CPAP, UPPP and others could be chosen according to the obstructive sites.

Clonazepam Treatment of Pathologic Childhood Aerophagia with Psychological Stresses

The treatment of pathologic aerophagia has rarely been discussed in the literature. In this retrospective study, the authors investigated the effects of clonazepam on the management of pathologic childhood aerophagia (PCA) with psychological stresses (PS), but not with mental retardation. Data from 22 consecutive PCA patients with PS (aged 2 to 10 yr), who had been followed up for over 1 yr, were reviewed. On the basis of videolaryngoscopic views, the authors observed that the pathology of aerophagia was the result of reflex-induced swallowing with paroxysmal openings of the upper esophageal sphincter due to unknown factors and also observed that these reflex-induced openings were subsided after intravenous low dose benzodiazepine administration. Hence, clonazepam was administered to treat paroxysmal openings in these PCA patients with PS. Remission positivity was defined as symptom-free for a consecutive 1 month within 6 months of treatment. The results of treatment in 22 PCA patients with PS were analyzed. A remission positive state was documented in 14.3% of PCA patients managed by reassurance, and in 66.7% of PCA patients treated with clonazepam (p=0.032). Thus, clonazepam may produce positive results in PCA with PS. Future studies by randomized and placebo-controlled trials are needed to confirm the favorable effect of clonazepam in PCA.

Prevalence and Related Parameters of Daytime Sleepiness in Patients with Habitual Snoring

BACKGROUND: Excessive daytime sleepiness (EDS) is a common symptom in patients with habitual snoring, including obstructive sleep apnea (OSA). However, there had been no studies for the prevalence and related factors of EDS in patients with habitual snoring in Korea. So we studied the prevalence and related factors of EDS in patients with habitual snoring. METHODS: Sixty two patients with habitual snoring were selected from our sleep center from February 2004 to January 2007. All patients were given an overnight polysomnography and then took the multiple sleep latency tests the following day. They were classified into two groups: EDS (mean sleep latency, MSL or =10 minutes). We studied the prevalence of EDS in patients with habitual snoring and compared two groups about the demographic data and polysomnographic characteristics. RESULTS: Most (72.6%) patients with habitual snoring demonstrated EDS. There were significant different parameters between the EDS group and the no EDS group, such as total sleep time, percent of slow wave sleep, snoring index, arousal index, and number of desaturation. Among these, the logistic regression analysis identified total sleep time as a significant predictive factor for daytime sleepiness. MSL correlated significantly with the percent of slow wave sleep and number of desaturation. CONCLUSIONS: Our results showed the high prevalence of EDS in patients with habitual snoring in Korea. Long total sleep time in polysomnography seems to predict EDS.

Effect of Topical Antibiotics to Mouse Model of Acute Rhinosinusitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES : Administration of antibiotics is an essential modality to treat acute rhinosinusitis. Although intranasal inoculation of antibiotics does not have definite bioavailability, it is a very effective method to treat acute rhinosinusitis. We made a mouse model of rhinosinusitis by inoculation of Streptococcus pneumoniae and administrated time-dependent antibiotics or concentration-dependent antibiotics as a topical manner and investigated their effectiveness. SUBJECTS AND METHOD : Fifty 10-week old male C57BL/6 mice were employed for acute rhinosinusitis model. Mice were inoculated with Streptococcus pneumoniae, and from the 6th to 10th day, we made the negative control group by inoculation of normal saline (Group I), the antibiotics group by inoculation of cefmenoxime & vancomycin (Group II), the ofloxacin & tobramycin group (Group III), and the positive control group (Group IV). On the 11th day, all mice were sacrificed and the effectiveness of antibiotics was evaluated by comparison of nasal lavage colony count and neutrophil count of the sinonasal tissue. RESULTS : Minimum bactericidal concentration (MBC) of each antibiotics was cefmenoxime 20 microgram/ml, ofloxacin 80 microgram/ml, tobramycin 25 microgram/ml, vancomycin 12.5 microgram/ml. By nasal lavage, antibiotics inoculation group (Group II, III) had more decreased bacterial growth than the positive control, and it was statistically significant (p=0.037). Comparision between the group administrated with concentration-dependent antibiotics and time-dependent antibiotics, clusters of neutrophil decreased in two groups compared to positive control revealed that the group administered with concentration-dependent antibiotics had fewer clusters of neutrophil than the group administered with time-dependent antibiotics, and it was statistically significant. CONCLUSION : Local inoculation of concentration dependent antibiotics could be a more effective way to treat acute rhinosinusitis induced by Streptococcus pneumoniae than time dependent antibiotics.

A Mouse Model of Chronic Rhinosinusitis Induced by Streptococcus Pneumoniae / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: A mouse has a great potential to be used in studying genetics and inflammatory process of the rhinosinusitis. The aim of this study was to observe effects of experimentally induced chronic rhinosinusitis on histopathology of the sinonasal mucosa in a mouse and to develop a chronic form of rhinosinusitis. MATERIALS AND METHOD: Thirty five, six-week old male C57BL/6 mice were used as follows: 7 normal controls without intervention, 7 Sham operated controls, 7 animals with ostial obstruction alone using Merocel, 7 animals implanted with Merocel plus 106 colony forming unit (CFU)/mL of Streptococcus pneumoniae and 7 animals implanted with Merocel plus 10(8) CFU/mL of S. pneumoniae. Six weeks after intervention, the animals were sacrificed and serially sectioned at 1 mm intervals and stained with Hematoxylin and Eosin. RESULTS: Increased epithelial thickness, goblet cell hyperplasia, epithelial disarray and inflammatory infiltration were observed in the experimental sinuses packed with Merocel alone or Merocel with bacterial inoculation, especially at the nasal septal area. However, there were no significant differences between the Merocel only inserted group and Merocel and bacteria inoculated group. CONCLUSION: Maxillary sinus ostial obstruction or ostial obstruction with S. pneumoniae inoculation induced chronic rhinosinusitis in C57BL/6 mice as indicated by the histologic change. This study could be used as a model of chronic rhinosinusitis for further study.

Predictive Clinical Factors for the Treatment Response and Relapse Rate in Childhood Idiopathic Nephrotic Syndrome

PURPOSE: This study was aimed to determine the predictive risk factors for the treatment response and relapse rate in children diagnosed with idiopathic nephrotic syndrome. METHODS: We analyzed the medical records of children who were diagnosed and treated for childhood idiopathic nephrotic syndrome from November 1991 to May 2005. Variables selected in this study were age at onset, sex, laboratory data, concomitant bacterial infections, days to remission, and interval to first relapse. RESULTS: There were 46 males and 11 females, giving a male:female ratio of 4.2:1. The age(mean+/-SD) of patients was 5.8+/-4.1 years old. Of all patients who were initially given corticosteroids, complete remission(CR) was observed in 54(94.7%). Of the 54 patients who showed CR with initial treatment, 40(70.2%) showed CR within 2 weeks and 14(24.6%) showed CR after 2 weeks. The levels of serum IgG were lower in the latter group who showed CR after 2 weeks(P=0.036). Of the 54 patients who showed CR with initial treatment, 47(82.5%) relapsed. Of these patients, 35.1% were frequent relapsers and 43.9% were infrequent relapsers. There was no significant correlation between the frequency of relapse and the following variables:sex, days to remission, and laboratory data. However, age at onset and interval to first relapse had a negative correlation with the frequency of relapse (Pearson's coefficient=-0.337, -0.433, P<0.012, P<0.01). CONCLUSION: The age at onset and the interval to first relapse were found to be predictive clinical parameters for the relapse rate, while the levels of serum IgG at initial presentation were a predictive laboratory factor for treatment response in childhood idiopathic nephrotic syndrome.

Effect of GnRH analogue on predicted adult height in girls with early puberty / 소아과

PURPOSE: The recent results observed in precocious puberty and the hope that interrupting puberty might increase adult height have led to an attempt to use GnRH agonist(GnRHa) in children with premature puberty and a poor growth prognosis. We aimed to analyze the growth promoting effect of GnRHa in girls with early puberty and low predicted adult height(PAH). METHODS: Thirty six girls were recruited. They were grouped according to the GnRHa treatment period(group 1>6 mo, n=18; group 2<6 mo, n=18). The following variables were analyzed before and after GnRHa treatment:chronological age(CA), bone age(BA), delta age(CA-BA), height, target height (TH), PAH, serum IGF-1, IGFBP-3. RESULTS: Duration of the GnRHa treatment was 0.89+/-0.81 yr(1.37+/-0.92 yr in group 1, and 0.41+/-0.08 yr in group 2). Before treatment, none of the variables were different between the two groups. There were no differences in the following variables the between two groups at the end of treatment:CA, BA, delta age, PAH, serum IGF-1, IGFBP-3. But, growth velocity(GV) and PAH increment during treatment were significantly reduced in group 1. Compared with initial PAH, PAH at the end of treatment was significantly increased(3.7+/-3.2 cm). The last serum levels of IGF-1 and IGFBP-3 were lower than those before treatment. CONCLUSION: Even though last PAH didn't approach TH, short term GnRHa administration in early puberty with low predicted PAH was somewhat effective. But, GnRHa administration suppressed the growth hormone-IGF-1 axis. Therefore, it is recommended that growth hormone(GH) should be used in combination with GnRHa.

A Case of Neonatal Lupus Erythematosus Associated with Anti-U1RNP Antibodies / 소아과

Neonatal lupus erythematosus(NLE) is a distinct subset of lupus characterized by cutaneous findings, cardiac conduction defects, hepatic or hematologic abnormalities. These manifestations are associated with the presence of maternal auto-antibodies such as anti-SSA/Ro, anti-SSB/La, and rarely anti- RNP(U1RNP) antibodies. Cases of U1RNP antibody-positive NLE have somewhat atypical cutaneous manifestation without cardiac or systemic abnormalities. We report a case of cutaneous NLE associated with U1RNP antibodies.

An Evaluation of Apnea-Hypopnea Index, Sleep Questionnaires, Oropharyngeal Findings and Cephalometric Parameters in Patients with Snoring

BACKGROUND: Although obstructive sleep apnea (OSA) is a common disorder, it often goes undiagnosed due to limited availability of the polysomnography (PSG) and a lack of interest in this condition. The aim of this study was to investigate the relationship between severities of obstructive sleep apnea, sleep questionnaires, oropharyngeal findings and cephalometric parameters in patients whom snore. METHODS: Fifty-seven (46 males) patients presenting snoring or other symptoms of OSA were evaluated retrospectively at the sleep disorder clinic in Keimyung University, Dongsan Medical Center were included in this study. All patients completed an overnight polysomnography, several sleep questionnaires and oropharyngic and cephalometric examinations. The sleep questionnaires included the Stanford Sleepiness Scale (SSS), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and Beck Depression Inventory (BDI). The oropharyngeal examinations included tonsil grade and modified Mallampati grade. RESULTS: There were altogether 42 (38 male) patients diagnosed with OSA. The mean age of the patients was 42.4 +/- 12.8 years, the body mass index (BMI) was 26.1 +/- 2.7 kg/m2 and the apnea-hypopnea index (AHI) was 28.1 3 +/- 0.3. Sex difference (male), BMI, tonsil grade and some parameters of the cephalometric examination had a significant positive correlation with the AHI. However, the AHI correlated poorly with the sleep questionnaires. CONCLUSIONS: Although tonsil grade, modified Mallampati grade and some parameters of the cephalometric examination can be utilized as a useful method to evaluate OSA, the AHI correlated poorly with self-reported sleep questionnaires. These findings suggest that the severity of sleep apnea should be quantified with both physiologic and subjective measures.

Delayed Facial Nerve Paralysis after Middle Ear and Mastoid Surgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The purpose of this study was to provide possible causes and post-treatment prognosis of delayed facial nerve palsy (DFP) following middle ear and mastoid surgery. SUBJECTS AND METHOD: The medical records of 3787 cases of middle ear and mastoid surgery from June, 1980 to August, 2003 were retrospectively reviewed. Nine cases developed ipsilateral facial nerve palsy after 72 hours of surgery. Their age ranged from 20 to 67 years (the mean of 40 years old and the male: female ratio of 1:1.25). For the review of the chart, we checked preoperative middle ear and mastoid state, intraoperative findings, clinical features of development and recovery of facial nerve palsy. To evaluate the degree and the possibility of recovery of facial nerve palsy, the House-Blackman grading system was used and electrophysiologic studies (Maximal stimulation test, Nerve excitability test and Nerve conduction velocity test) were performed. The steroid and vasodilator drugs were prescribed for the treatment. RESULTS: All of the nine patients had preoperative diagnosis of chronic otitis media and five of them also had cholesteatoma. Radical mastoidectomy was done in two cases, open cavity techniques in two cases and closed cavity techniques in five cases. There were postoperative wound infections in five cases. Facial palsy was developed between 5th and 16th postoperative day (mean 9th day) and the initial House-Blackman grade was II or III. The time for complete recovery ranged from 1 month to 6 months, with the fastest recovery time being 9 days after DFP. CONCLUSION: DFP following middle ear and mastoid surgery is an unpredictable complication. Postoperative wound infection may have been related to it and should be regarded as a risk factor of DFP.