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Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians’ grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians’ care based on their experience and assessment of individual patients.

The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.

The increasing prevalence of obstructive sleep apnoea (OSA) led to the need to understand upper airway (UA) anatomy and its contribution to the disease process. This review article summarises the current understanding of OSA development in adults. It focuses on UA anatomy and pathophysiology in anatomical subsites including the nasal cavity, soft tissue, and bony frameworks. This article also describes research trends in the context of anatomy. The research investigated pathophysiological phenotypes and their correlation with anatomy, phenotype labelling using drug-induced sleep endoscopy and their clinical characteristics, and recent updates regarding non-invasive tools for diagnosing sites of obstruction in individuals with OSA.

Abstract Background Nasotracheal intubation is a very useful technique for orofacial or dental surgery. However, the technique itself can be more traumatic than that of orotracheal intubation. Complications such as turbinectomy or bleeding are often reported. However, little is known about the follow-up of patients after these complications. Case presentation The present case describes an accidental middle turbinectomy that led to endotracheal tube obstruction during nasotracheal intubation, and discusses its long-term follow-up. A 19-year-old man underwent mandibular surgery under general anesthesia and nasotracheal intubation. His right middle turbinate was completely avulsed and became firmly occluded within the tube during nasotracheal intubation. The nasotracheal intubation was performed again and the operation was completed safely. The patient was discharged without sequelae after postoperative care. However, he had symptoms of nasal obstruction and sleep disturbance for 3 months postoperatively. Synechiae were detected between the nasal septum and lateral nasal wall on a right rhinoscopic examination and facial computed tomography at 3 months postoperatively. Additionally, he showed ipsilateral maxillary sinusitis on facial computed tomography at the 2-year follow-up examination. Conclusions Nasotracheal intubation can cause late complications as well as early complications. Therefore, if nasotracheal intubation is to be performed, the anesthesiologist should identify the nasal anatomy of the patient accurately and prepare appropriately. In addition, if complications occur, follow-up observation should be performed.

Background and Objectives Treatment choice for fungal ball is endoscopic endonasal removal. However, it is not easy to remove fungal elements from the maxilla using only an endonasal approach. To overcome this difficulty, we introduced a cotton pledget technique and evaluated its efficacy through a cadaveric study and clinical research. Materials and Method A cadaveric study was performed using 10 half heads of seven cadavers. The ease and safety of the cotton pledget technique were compared to those of a previously reported technique. In clinical research, we enrolled 52 patients who underwent surgery with the cotton pledget technique and 36 patients who underwent surgery using the conventional endoscopic approach. Demographic factors, preoperative Lund-Mackay (LM) score, sinonasal outcome test (SNOT) score, surgical morbidity, and incomplete removal rate were analyzed. Results The cadaveric study showed that the cotton pledget technique was easier (p=0.011) than the conventional technique. In addition, clinical evaluation showed that the cotton pledget group had significantly lower incomplete removal rate than that of the control group (p=0.010). Conclusion The cotton pledget technique is an easy and safe method that enables fungal ball removal more effectively than the conventional technique without need for inferior meatal antrostomy (IMA) or the Caldwell-Luc (CL) approach.

PurposeHead rotation is thought to have an effect on obstructive sleep apnea (OSA) severity. However, keeping the head rotated fully during sleep is difficult to maintain, and the effect of head rotation is not the same in all OSA patients. Thus, this study aimed to identify whether less head rotation has an effect on airway patency and determine the responder characteristics to the head rotation maneuver (HRM).MethodsWe recruited 221 patients who underwent overnight polysomnography and drug-induced sleep endoscopy (DISE) in a tertiary hospital from June 2019 to July 2020. Airway patency and the site of airway collapse were determined in the supine position with the head at 0, 30, and 60 degrees of rotation (HRM0°, HRM30°, and HRM60°, respectively) during DISE. The site of collapse was determined using the VOTE classification system: the velum (palate), oropharyngeal lateral walls, tongue base, and epiglottis. Each structure was labeled as 0, 1, or 2 (patent, partially obstructed, and completely obstructed, respectively). Airway response to the HRM30° and 60° and the clinical characteristics associated with airway opening were analyzed.ResultsThe study population had a median age of 52 (25-61) years, a body mass index of 26.7(24.6-29.4) kg/m2, and the apnea-hypopnea index (AHI) of 28.2(13.7-71.9) events/h. HRM influenced airway patency positively not only with HRM60° (pConclusionHead rotation improved airway obstruction in OSA patients, even with a small degree of rotation, and should be further explored as a potential form of therapy in appropriately selected patients.

Medicinal plants and their extracts have been used as important sources for drug discovery. In particular, plant-derived natural compounds, including phytochemicals, antioxidants, vitamins, and minerals, are gaining attention as they promote health and prevent disease. Although several in vitro methods have been developed to confirm the biological activities of natural compounds, there is still considerable room to reduce time and cost. To overcome these limitations, several in silico methods have been proposed for conducting large-scale analysis, but they are still limited in terms of dealing with incomplete and heterogeneous natural compound data. Here, we propose a deep learning-based approach to identify the medicinal uses of natural compounds by exploiting massive and heterogeneous drug and natural compound data. The rationale behind this approach is that deep learning can effectively utilize heterogeneous features to alleviate incomplete information. Based on latent knowledge, molecular interactions, and chemical property features, we generated 686 dimensional features for 4,507 natural compounds and 2,882 approved and investigational drugs. The deep learning model was trained using the generated features and verified drug indication information. When the features of natural compounds were applied as input to the trained model, potential efficacies were successfully predicted with high accuracy, sensitivity, and specificity.

Abstract Background In intubation using fiberoptic bronchoscope (FOB), partial or complete obstruction of upper airway makes the FOB insertion difficult. Thus, maneuvers to relieve such obstructions are recommended. There have been no studies to determine whether the sniffing or neutral position is superior for this purpose. Therefore, this study was performed to examine the effects of these two positions including vocal cord view. Methods Fifty-four patients scheduled to receive general anesthesia by orotracheal intubation were eligible for inclusion in the study with informed consent. After confirmation of proper head positioning depending on the group, the view of the vocal cord was acquired in each position. Images were reviewed using the percentage of glottic opening (POGO) score. Results A total of 106 images of vocal cords from 53 patients were obtained. The mean of difference of POGO score was 11.09, higher for the neutral position and standard deviation was 23.73 (p = 0.002). Neutral position increased POGO score in 31 patients and decreased POGO score in 13 patients compare to sniffing position (p = 0.017). There were no significant differences between the two head positions with regard to intubation time or degree of convenience during intubation. Conclusions Neutral position improved the view of glottic opening than sniffing position during oral fiberoptic intubation. However, there was no difference in the difficulty of tube insertion between the two positions. Trial registration Clinical Trials.gov identifier: NCT02931019, registered on October 12, 2016.

IntroductionTo overcome the limited readability of the conventional drug induced sleep endoscopy (DISE) system which only records flexible endoscopy images, we devised the Multimodality DISE System (MDS). MDS encompasses the monitoring systems for oxygen saturation, electrocardiogram, blood pressure, snoring intensity, and patient's position. It enabled to record comprehensive situation of patients who underwent DISE. In this study, we compared the efficacy of MDS with that of the conventional DISE system.Methods and materialsTen patients underwent DISE at a tertiary hospital. DISE evaluated the airway of each patient in four positions; supine, supine with jaw thrust, right lateral decubitus, and left lateral decubitus. In addition, every examination was recorded by using both single monitoring system and MDS system. Five otolaryngologists interpreted the recorded examinations without knowledge of patient information (10 conventional DISE and 10 MDS). The visual analogue scale (VAS) scores for readability, reading times, ease of patient explanation and the ease of decision making were analyzed.ResultsMean VAS scores for readability of conventional DISE and MDS were 4.41+2.56 and 8.42+2.07 (pConclusionsMDS enhanced the readability of previously recorded DISE and enabled easier doctor-patient communication. In addition, MDS is more effective in decision making regarding patients with OSA. MDS has laid the groundwork for separating the DISE prescriber from the DISE performer.

ObjectivesAutologous costal cartilage is a promising alternative for mastoid obliteration. However, donor-site morbidities of the chest wall limit the use of this graft. To address this issue, we have developed a minimally-invasive technique of harvesting costal cartilage and report donor site morbidity associated with the procedure.MethodsDonor site morbidities were evaluated for 151 patients who underwent costal cartilage harvest, canal wall down mastoidectomy, and mastoid obliteration. Pain and cosmetic concern were evaluated via visual analogue scale (VAS). Scars were evaluated via the modified Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). Postoperative complications were assessed during the follow-up period.ResultsThe mean duration of noticeable pain was 5.3 days post operation. The mean VAS score for pain was 3.0 of 10 on the first day after the operation and gradually declined. At the 6 months post operation, the mean VAS cosmetic score at the costal cartilage harvest site was 0.6 of 10. The mean VSS score was 9.5 out of 10 total, and the mean POSAS score was 23.27 out of 110 total.ConclusionThe minimally-invasive chopped costal cartilage harvest technique resulted in acceptable pain, cosmetic concern, and postoperative complications for most patients. There were no major postoperative complications. Costal cartilage is an acceptable donor for mastoid obliteration in canal wall down mastoidectomy, especially in the context of the extremely low donor site morbidity of the minimally-invasive technique presented in the study.

ObjectivesVascular leiomyoma is an uncommon benign tumor of smooth muscle origin that arises from the muscularis layer of blood vessel walls. We report our experiences with the clinical manifestations, pathologic characteristics, and management of vascular leiomyoma in the head and neck.MethodsThe clinical records of 12 patients with vascular leiomyoma of the head and neck in the 11-year period were reviewed retrospectively.ResultsThe 12 patients included nine men and three women. The locations of the tumors were variable, including nasal cavity, auricle, hard palate, upper lip, upper eyelid, and supraclavicular space. All but three patients reported an asymptomatic spherical mass; the other three patients complained of intermittent epistaxis or unilateral nasal obstruction resulting from the tumor originating in the nasal cavity. All tumors were painless. Computed tomography consistently revealed a well-defined, intensely enhanced small mass on the mucosa. No case was dignosed corretly as vascular leiomyoma before surgical excision. All patients underwent localized surgical excision of the tumor without recurrence. Five of 12 tumors (42%) were of solid type, four (33%) were of venous type, and three (25%) were of cavernous in histological classification. The histologic type was not related to gender, site of occurrence, and presence of pain.ConclusionVascular leiomyoma presents as a small, painless mass in various locations of the head and neck region. Localized surgical excision is the only way to make the diagnosis and yields excellent results.

The potential complications of cotton bud use are not well known in the elderly population. Here, we presented a case of cotton bud misuse. An elderly man who had long-standing diabetes mellitus, chronic otorrhea, and right-sided otalgia was poorly responsive to empirical treatment at a primary hospital. He was misdiagnosed with malignant otitis externa and referred to a tertiary hospital. On treatment Day 7 at the tertiary hospital, when the swollen ear canal was somewhat resolved, a retained cotton swab was found in his ear canal. His symptoms rapidly resolved after removing the retained foreign body. A cotton bud can be retained as a foreign body in the ear canal. The guidance of health professionals is needed to clean the ear canal using cotton buds, especially for elderly patients with other chronic diseases.

Rationale: Obstructive sleep apnea is characterized by frequent reductions in ventilation, leading to oxygen desaturations and/or arousals. Objectives: In this study, association of hypoxic burden with incident cardiovascular disease (CVD) was examined and compared with that of "ventilatory burden" and "arousal burden." Finally, we assessed the extent to which the ventilatory burden, visceral obesity, and lung function explain variations in hypoxic burden. Methods: Hypoxic, ventilatory, and arousal burdens were measured from baseline polysomnograms in the Multi-Ethnic Study of Atherosclerosis (MESA) and the Osteoporotic Fractures in Men (MrOS) studies. Ventilatory burden was defined as eventspecific area under ventilation signal (mean normalized, area under the mean), and arousal burden was defined as the normalized cumulative duration of all arousals. The adjusted hazard ratios for incident CVD and mortality were calculated. Exploratory analyses quantified contributions to hypoxic burden of ventilatory burden, baseline oxygen saturation as measured by pulse oximetry, visceral obesity, and spirometry parameters. Measurements and Main Results: Hypoxic and ventilatory burdens were significantly associated with incident CVD (adjusted hazard ratio [95% confidence interval] per 1 SD increase in hypoxic burden: MESA, 1.45 [1.14, 1.84]; MrOS, 1.13 [1.02, 1.26]; ventilatory burden: MESA, 1.38 [1.11, 1.72]; MrOS, 1.12 [1.01, 1.25]), whereas arousal burden was not. Similar associations with mortality were also observed. Finally, 78% of variation in hypoxic burden was explained by ventilatory burden, whereas other factors explained only ,2% of variation. Conclusions: Hypoxic and ventilatory burden predicted CVD morbidity and mortality in two population-based studies. Hypoxic burden is minimally affected by measures of adiposity and captures the risk attributable to ventilatory burden of obstructive sleep apnea rather than a tendency to desaturate. [ABSTRACT FROM AUTHOR]

Rationale: A low respiratory arousal threshold is a key endotype responsible for obstructive sleep apnea (OSA) pathogenesis. Pimavanserin is an antiserotoninergic capable of suppressing CO2-mediated arousals without affecting the respiratory motor response in animal models, and thus it holds potential for increasing the arousal threshold in OSA and subsequently reducing OSA severity. Objectives: We measured the effect of pimavanserin on arousal threshold (primary outcome), OSA severity, arousal index, and other OSA endotypes (secondary outcomes). Methods: A total of 18 OSA participants were studied in a randomized, double-blind, crossover study. Patients received a single dose of placebo or pimavanserin 34 mg 4 hours before in-lab polysomnography. Airflow was measured with an oronasal mask attached to a pneumotachograph, and ventilatory drive was recorded with an intraesophageal electromyography catheter. Results are presented as mean or median changes (Δ) and 95% confidence intervals (CIs). Results: Pimavanserin did not increase the arousal threshold, nor did it decrease OSA severity or arousal index. It, however, prolonged total sleep time (Δ[confidence interval (CI)], 39.5 [95%CI, -1.2 to 80.1] min). In an exploratory analysis, a subgroup of seven patients who had a 10% or more increase in arousal threshold on pimavanserin exhibited a decrease in AHI4 (hypopneas associated with 4% desaturation) (Δ[CI], 5.6 [95%CI, 3.6-11.1] events/h) and hypoxic burden (Δ[CI], 22.3 [95%CI, 6.6-32.3] %min/h). Conclusions: A single dose of pimavanserin did not have a significant effect on arousal threshold or OSA severity. However, in a post hoc analysis, a subset of patients who exhibited an increase in arousal threshold on pimavanserin showed a small decrease in OSA severity. Thus, if the arousal threshold could be increased with pimavanserin, perhaps with longer dosing to reach higher drug blood concentrations, then the desired effect on OSA severity might be achievable. Clinical trial registered with ClinicalTrials.gov (NCT04538755). [ABSTRACT FROM AUTHOR]

Rationale: The anatomic orientation of the epiglottis is such that it points in the opposite direction to inspiratory flow, thereby potentially making positive airway pressure (PAP) treatment challenging in patients with epiglottic collapse. However, no previous studies have analyzed PAP adherence in these patients. Objectives: This study aimed to analyze adherence to autotitrating PAP (APAP) treatment in patients with epiglottic collapse. Methods: We performed an age- and sex-matched case-control study. On the basis of their overnight level-I polysomnogram, patients were prescribed APAP in a tertiary hospital between July 2018 and March 2019. The site of airway collapse was diagnosed with drug-induced sleep endoscopy. Demographic factors, sleep questionnaire, polysomnography, and APAP usage statistics were analyzed. Results: Eighteen patients with epiglottic collapse (epi-group) and 36 without epiglottic collapse (control group) were analyzed. We found that 22.8% of patients in the epi-group terminated APAP within 2 weeks, whereas only 2.8% of patients in the control group terminated APAP within 2 weeks (P = 0.048). The percentage of days with usage over 4 hours was significantly lower in the epi-group (64.6% vs. 75.6%; P = 0.008). In addition, the adherence failure rate was 66.7% in the epi-group and 33.3% in the control group (P = 0.039). Patients with epiglottic collapse were also found to have lower body mass index, which is an unfavorable predictor of APAP adherence. Conclusions: This study suggests that patients with epiglottic collapse have a higher APAP adherence failure rate than patients without epiglottic collapse. Thus, patients with epiglottic collapse should be followed closely during treatment, and alternative therapies should probably be considered for these patients. [ABSTRACT FROM AUTHOR]

The article examines the clinical characteristics of the site of obstruction in sleep apnea in terms of the associations with disease severity, obesity and implications for mechanical interventions. Topics discussed include probability of epiglottic obstruction, drug-induced sleep endoscopy (DISE), and expected treatment response according to phenotype labeling using DISE.

Background: The treatment of choice for maxillary fungal ball (FB) is surgical removal; however, surgeons hesitate to perform surgery, especially in elderly individuals, under general anesthesia (G/A). So instead of G/A, this study evaluated the outcome of FB removal under local anesthesia (L/A). Methods: Three analyses were included in this study. First, the demographic characteristics of patients with FB were analyzed via a retrospective chart review of 3,681 individuals who underwent otolaryngologic surgery; FB, chronic sinusitis (CRS), chronic otitis media, deviated septum, and enlarged tonsil. Second, the clinical characteristics of patients who had surgery for FB under L/A were compared to those of patients who had surgery for CRS under L/A via age-sex matched case-control analyses. Third, the clinical characteristics of elderly patients with FB were compared to those of non-elderly patients. Results: Comparisons within the otorhinolaryngological disease group showed that patients with FB were older and had a higher proportion of women than the other groups. Age- and sex-matched case-control analyses with the CRS group revealed that FB patients complained of less pain (p = 0.05) and reported more satisfaction with L/A than the CRS group (p = 0.002). Analyses by age group showed that elderly patients with FB had lower sinonasal outcome test scores but higher Lund-Mackay scores. Conclusion: Old age, diabetes, and hypertension, which may increase the risk for general anesthesia, are characteristic of patients with FB in this study. However, patients who underwent FB removal under L/A had relatively less pain, greater satisfaction than CRS with L/A. Thus, surgical removal under L/A is a safe, reasonable option for patients with FB. [ABSTRACT FROM AUTHOR]

We report a rare case where Q-tip induced mixed hearing loss without perilymph fistula and demonstrate the need for computed tomography imaging with three-dimensional reconstruction where fracture and dislocation of the stapes are suspected. A 28-year-old male experienced an accidental penetrating injury by a Q-tip in the right ear 6 years previously.Temporal bone computed tomography revealed a dislocation of the stapes and incus. A volume-rendered three-dimensional reconstruction revealed that the stapes was rotated 180° laterally toward the handle of the malleus. Exploratory tympanotomy revealed dislocation of the incus and superstructure of the stapes, with an intact tympanic membrane. The patient's hearing was successfully improved by ossiculoplasty (malleus-footplate assembly) using autologous incus. To differentiate stapes fracture with dislocation as the cause of traumatic conductive hearing loss, three-dimensional reconstruction of the temporal bone computed tomography is helpful before exploratory tympanotomy. [ABSTRACT FROM AUTHOR]

Epistaxis is one of the common causes of emergency department (ED) visits. However, most cases are not severe and undergo an unnecessary medical evaluation, especially in non-traumatic epistaxis. This study investigated how many patients require a definite observational unit (DOU) and what factors are associated with DOU among nontraumatic epistaxis patients. This retrospective observational study included 1197 nontraumatic epistaxis patients who visited the ED from January 2016 to December 2020. Multiple logistic regression analysis was performed to evaluate the association between risk factors and DOU care. In addition, the receiver operating characteristic (ROC) curve for predicting DOU care was analyzed to estimate the diagnostic ability of risk factors. A total number of 1122 patients with non-traumatic epistaxis were included in the final analysis. Among them, 41 (3.65%) patients needed DOU care. Male sex (odds ratio (OR) = 3.606, p = 0.003), hypertension (OR = 2.362, p = 0.020), inter-hospital transfer (OR = 2.358, p = 0.039), verbal mental status (OR = 29.436, p = 0.035), hemoglobin (Hb) level (OR = 0.724, p < 0.001), revisit after initial discharge for epistaxis (OR = 8.813, p < 0.001), and delayed ED arrival (≥180 min) (OR = 2.451, p = 0.030) were significant factors for DOU care. In addition, the area under the curve of the multiple logistic regression model for predicting DOU care was 0.870. Among the patients who visited ED due to non-traumatic epistaxis, only 3.65% of patients required DOU care. Male sex, mental status, Hb level, ED revisit after initial discharge, inter-hospital transfer and delayed ED arrival (>180 min) were associated with DOU care. These findings will help to triage epistaxis patients before they visit the ED. [ABSTRACT FROM AUTHOR]