Jong-Yeup Kim

Intratympanic dexamethasone injection for refractory tinnitus: Prospective placebo‐controlled study

The purpose of this study is to investigate the effectiveness of intratympanic dexamethasone injections (ITDI) for refractory tinnitus.

Feasibility of septal body volume reduction for patients with nasal obstruction.

Septal body hypertrophy, like inferior turbinate hypertrophy, can result in changes to the nasal cross‐sectional area and resistance to airflow. The aim of this study is to evaluate the efficacy of septal body volume reduction (SBVR) for the treatment of septal body hypertrophy in patients with nasal obstruction.

Combined use of scoring incisions and 2-octylcyanoacrylate adhesive during endonasal septoplasty to correct cartilaginous deviations.

Background Applying 2-octylcyanoacrylate (2-OCA) tissue adhesive onto scoring incisions may increase efficacy and prevent concavity recurrence after septal deviation treatment. The present study evaluates the utility of 2-OCA adhesive application during endonasal septoplasty. Methods The postoperative outcomes were compared between two consecutive periods in a single surgical department. Between March 2011 and March 2012, 23 consecutive patients underwent septoplasty using scoring incisions without 2-OCA application (scoring alone group), and between April 2012 and April 2013, the scoring incision gaps were filled with 2-OCA in 27 patients (scoring + CA group). The patients were followed up for more than six months. Results A straight septum was achieved in 37.0% of patients in the scoring alone group versus 58.3% in the scoring + CA group. The postoperative symptom score for nasal obstruction was significantly improved in both groups. Persistent septal swelling developed in three (12.5%) patients in the scoring + CA group. Neither group experienced major complications such as septal hematoma, abscess, or septal perforation. Conclusions Application of 2-OCA adhesive onto scoring incisions appears to be a reliable and effective technique to correct deviated cartilage during endonasal septoplasty. However, the volume of 2-OCA applied onto the septum should be minimized to avoid potential foreign body reaction. A long-term follow-up study is warranted.

Endonasal extended columellar strut in Asian rhinoplasty.

Background Recently, sculpturing of projected and sharp nasal tips, as is usual in the white population, has been of great concern in Asian rhinoplasty. However, tip surgery in Asians should be performed in a different way due to anatomic differences. The authors used an endonasal rhinoplasty to correct the position of lower lateral cartilage by adopting a modified columellar strut. This novel technique of an endonasal extended columellar strut (EECS) could project the nasal tip significantly while avoiding hard fixation. This study aimed to evaluate the usefulness of the EECS in Asians. Materials and Methods A retrospective study was performed with 40 patients who underwent EECS from March 2012 to August 2014. Photographs taken preoperatively and postoperatively were analyzed. The tip projection, the ratio of the length of the infratip lobule to the total length of the tip, and a columellar labial angle change were measured. Overall, surgical outcomes were rated into three grades (excellent, good, and fair) by two experienced rhinoplasty surgeons (J.Y.K., M.S.C.). All the patients were asked to rate their cosmetic satisfaction by using a visual analog scale (10 points). Results Postoperative nasal tip projection significantly increased, from 24.2 to 26.7 mm (p < 0.01). The ratio of the length of the infratip lobule to the total length of the tip mildly increased, from 0.45 to 046 in men, and remained unchanged, at 0.48, in women. The columellar labial angle significantly increased, from 86.9° to 93.7° (p < 0.01). Surgical outcomes were rated by two experienced surgeons as excellent (40%), good (42%), and fair (18%). Subjectively, patients graded their satisfaction at ∼8.7 on the visual analog scale. Conclusion This novel EECS technique enabled satisfactory tip projection in Asians while maintaining a natural ratio of infratip lobule to total length of tip and leaving no external scar.

Association of Sudden Sensorineural Hearing Loss With Risk of Cardiocerebrovascular Disease: A Study Using Data From the Korea National Health Insurance Service

Importance The interruption of vascular supply to the cochlea has been proposed as a major etiological factor for sudden sensorineural hearing loss (SSNHL), and several risk factors for cardiocerebrovascular disease (CCVD) are associated with SSNHL, including heavy smoking, alcohol consumption, and thromboembolic events. However, the link between SSNHL and CCVD has not been fully evaluated. Objective To investigate the association between SSNHL and CCVD. Design, Setting, and Participants A retrospective propensity score–matched cohort study was conducted using a nationwide representative sample from the National Sample Cohort 2002 through 2013 data from the Korea National Health Insurance Service. The SSNHL group (n = 154) included certain patients who were diagnosed with SSNHL between January 2003 and December 2005. The comparison group was selected (4 patients for every 1 patient with SSNHL; n = 616) using propensity score matching, according to sociodemographic factors and the year of enrollment. Each patient was monitored until 2013. Main Outcomes and Measures Survival analysis, the log-rank test, and Cox proportional hazards regression models were used to calculate the incidence, survival rate, and hazard ratio of CCVD for each group. Results Among the 770 patients, 385 (50.0%) were female and 370 (48.1%) were aged between 45 and 64 years. Of the total study population, 66 patients developed CCVD, such as stroke and acute myocardial infarction, during the 11-year follow-up period: 18 patients in the SSNHL group (incidence, 13.5 cases per 1000 person-years) and 48 from the comparison group (incidence, 7.5 cases per 1000 person-years). After adjustment for other factors, the hazard ratio of CCVD during the 11-year follow-up period was 2.18 times (95% CI, 1.20-3.96) greater for patients with SSNHL. An increased risk of stroke was associated with SSNHL (HR, 2.02; 95% CI, 1.16-3.51); however, there was no relation between SSNHL and risk of myocardial infarction (HR, 1.18; 95% CI, 0.25-5.50). Conclusions and Relevance This observational study using nationwide data suggests that SSNHL is associated with an increased incidence of CCVD, specifically stroke. Therefore, patient surveillance for signs of CCVD should be considered for patients who receive a diagnosis of SSNHL.

Radiofrequency turbinoplasty for nonallergic rhinitis in geriatric patients.

Background and Objective Radiofrequency (RF) turbinoplasty may be effective in treating nonallergic rhinitis in elderly patients. The present study evaluated the efficacy of nasal turbinate surgery with RF for the treatment of nonallergic rhinitis in elderly patients refractory to medical therapy. Methods A total of 35 consecutive patients older than 65 years of age (mean subject age, 75.5 ± 9.6 [standard deviation] years) with nonallergic rhinitis refractory to medical therapy who underwent RF turbinate surgery were enrolled in this study. The efficacy of RF turbinoplasty in treating nonallergic rhinitis in elderly patients was evaluated by using rhinoscopy and a visual analog scale score of nasal symptoms. Results The response rate of primary RF turbinate surgery for nonallergic rhinitis refractory to medical therapy was 68.6%. Postoperative symptom scores for rhinorrhea and nasal obstruction were significantly improved. Persistent crust formation developed in seven patients (20.0%). No patient experienced major complications (e.g., septal hematoma, abscess, septal perforation), but partial bone necrosis was observed in one patient. Conclusion RF turbinoplasty appeared to be effective for treating some nonallergic rhinitis symptoms in elderly patients, including rhinorrhea and nasal obstruction. These preliminary results are encouraging and warrant further investigation.

Role of epigenetics in the pathogenesis of chronic rhinosinusitis with nasal polyps

Chronic rhinosinusitis (CRS) is a highly prevalent disease characterized by mucosal inflammation of the nose and paranasal sinuses. CRS can be divided into two main categories, CRS with nasal polyps (NPs; CRSwNP) and CRS without NPs (CRSsNP). Although the pathophysiology of CRS remains unclear, DNA methylation has been implicated in the etiology of CRSwNP. The aim of the present study was to elucidate whether DNA methylation of specific genes is involved in the development of NPs. In total, 18 individuals were included in the present study, and were divided into three groups: CRSwNP (n=7), CRSsNP (n=7) and healthy controls (n=4). NP tissues were obtained from the seven patients with CRSwNP and biopsies of the inferior turbinate mucosa from all three groups were used as controls. Methylated genes detected by methyl-CpG-binding domain sequencing were validated by methylation-specific polymerase chain reaction (PCR), bisulfite sequencing, and reverse transcription-quantitative PCR (RT-qPCR). Methyl-CpG-binding domain sequencing identified 43,674 CpG islands in 518 genes. The promotor regions of 10 and 30 genes were hypermethylated and hypomethylated, respectively, in NP samples compared with controls. The top four genes with altered hypomethylation in NP tissues were, Keratin 19 (KRT19), nuclear receptor subfamily 2 group F member 2 (NR2F2), A Disintegrin-like And Metallopeptidase (Reprolysin Type) with Thrombospondin type 1 motif 1 (ADAMTS1) and zinc finger protein 222 (ZNF222). RT-qPCR demonstrated that the expression levels of KRT19, NR2F2 and ADAMTS1 were significantly increased in NP tissues; however, there was no difference in the levels of ZNF222 between NP and control tissues. Further studies are required to confirm the relevance of these epigenetic modifications in the mechanisms underlying NP formation.

Factors that Contribute to Disagreement in Satisfaction between Surgeons and Patients after Corrective Septorhinoplasty

Background Corrective septorhinoplasty is one of the most common facial plastic surgeries. However, surgeons and patients sometimes disagree about postoperative-outcome satisfaction after corrective septorhinoplasty. Objective We investigated the factors that influenced the disagreement in satisfaction between surgeons and patients after corrective septorhinoplasty. Methods Surgeon satisfaction was assessed by other plastic surgeons by comparing patient photographs taken at the preoperative and 12-month postoperative periods. Patient satisfaction was assessed by the Rhinoplasty Outcome Evaluation Questionnaire (ROEO) before surgery and 12 months after surgery. The dissatisfied group was defined as showing a negative change or no change in the ROEO quartile between baseline and 12 months after surgery. Results A total of 70 patients were included. No significant differences were observed between the satisfied and dissatisfied groups in sex, marital status, depression history, and major anesthetic problems. However, the dissatisfied group was significantly younger, more likely to be employed, and better educated than the satisfied group. In addition, a multivariate logistic regression analysis indicated that being highly educated was a predictor of disagreement in satisfaction between surgeons and patients. Conclusion Our findings indicated that highly educated patients who underwent corrective septorhinoplasty required more detailed preoperative guidance, including more complete information on the limitations of the surgery.

Association of Idiopathic Sudden Sensorineural Hearing Loss With Affective Disorders

Importance Patients with idiopathic sudden sensorineural hearing loss (ISSNHL) often experience permanent hearing impairment, which could result in psychological perturbations. However, the relationship between ISSNHL and affective disorders, including depression, anxiety, and bipolar disorder, has not been fully evaluated. Objective To investigate the potential relationship between ISSNHL and affective disorders using nationwide representative cohort sample data. Design, Setting, and Participants This study used a nationwide propensity score–matched cohort sample from the Korean National Health Insurance Service database from 2002 through 2013, which comprises data from approximately 1 million patients. The study included 1425 patients with ISSNHL and 7125 individuals without ISSNHL who were matched using propensity score matching, according to sociodemographic factors and enrollment year. Main Outcomes and Measures Survival analysis, the log-rank test, and Cox proportional hazards regression models were used to calculate the incidence, survival rate, and hazard ratio (HR) of developing affective disorders (anxiety, depression, and bipolar disorder) for each group. Results Of the total study population of 8550 (51.5% female), 961 developed affective disorders during the 11-year follow-up: 225 in the ISSNHL group (15.8%) and 736 in the comparison group (10.3%). We examined a total of 96 885.5 person-years (81 177.4 person-years in the comparison group and 15 708.1 person-years in the ISSNHL group). The incidence of affective disorders was 14.3 per 1000 person-years in the ISSNHL group and 9.1 per 1000 person-years in the comparison group. After adjustment for other factors, individuals with ISSNHL developed affective disorders more frequently than those in the comparison group (HR, 1.50; 95% CI, 1.30-1.75). Among the affective disorders, the HR of developing depression (HR, 1.66; 95% CI, 1.44-1.91) and anxiety disorder (HR, 1.79; 95% CI, 1.56-2.05) but not bipolar disorder (HR, 0.95; 95% CI, 0.54-1.70), was significantly greater in patients with ISSNHL. Conclusions and Relevance This cohort study suggests that ISSNHL is associated with an increased incidence of affective disorders, specifically depression and anxiety. Therefore, these findings suggest that clinicians should monitor patients with ISSNHL carefully, and take specific precautions to reduce their risk of depression and anxiety disorder.

In Response to Intratympanic dexamethasone injection for refractory tinnitus: Prospective placebo‐controlled study

We appreciate Dr. Chandrasekhar’s comments regarding our article entitled “Intratympanic Dexamethasone Injection for Refractory Tinnitus: Prospective Placebo-Controlled Study.” As you mentioned, we also have been concerned about the sample size in this study and in substance sufficiently discussed this point with the reviewers. Although we initially enrolled 35 patients, only 30 patients were able to complete this study due to the exclusion of five patients who failed to return for followup. In prospective study design, it would be relevant to calculate the sample size using sensitivity analysis and power calculation based on the primary outcome of interest. However, the control study of “saline injection” replacing intratympanic dexamethasone injection (ITDI) was very difficult to conduct because it was not easy to obtain the patients’ consent on intratympanic saline injection. To overcome this matter, the control study of ITDI has been commonly performed with drugs such as ginkgo biloba, alprazolam, oral carbamazepine, and so on. Until now, articles have been reported in which authors performed the control study of IT dexamethasone/methylprednisolone injection with saline injection. They enrolled 30 to 59 patients in their studies. As 30 patients were enrolled in our present study, we do not insist that ITDI in tinnitus is utterly useless. Nonetheless, we believe that the indication for ITDI in tinnitus needs careful selection. We admit that our study has limitation in sample size and further studies with larger sample sizes are necessary. Therefore, we are still in the process of studying the ITDI by various means for tinnitus. With regard to dexamethasone concentration, we used the concentration of 5 mg/ml with a commodified product. Although ITDI has been used more frequently in inner ear diseases, especially in sudden sensorineural hearing loss (SSNHL), the treatment protocols still vary among reported studies in the aspect of concentration and frequency (number and interval of injection). Moreover, ITDI protocols for patients with tinnitus were not well established when we planned and conducted this study. At that time, we recognized one study reported by Araujo et al. in which they used 4 mg/ml dexamethasone solution (once per week for 4 weeks) to severe and disabling tinnitus. In addition, ITDI (5 mg/ml, twice a week for 2 consecutive weeks) that was treated to refractory SSNHL in our clinic was considered as an effective treatment. Therefore, we expected that the protocol for refractory SSNHL used in our clinic can also be significantly effective in refractory tinnitus. As Dr. Chandrasekhar commented, the concentration range of corticosteroid considerably from 4 to 40 mg/ml for dexamethasone in inner ear diseases may produce inconsistent results. Fu Y et al. reported their clinical and laboratory data on the efficacy in ITDI as an initial combination therapy to systemic steroid in SSNHL. They concluded that 5 mg/ml concentration of dexamethasone (every other day for five times) did not accumulate the effect to systemic steroid and suggested that higher dexamethasone concentration of 10 mg and 20 mg improved the therapeutic effect, based on their animal study with a potential of clinical applications. On the other hand, Shim et al. used 5 mg/ml dexamethasone solution (4 consecutive days) for acute tinnitus and reported that the therapeutic effect of ITDI plus alprazolam is superior to that of alprazolam alone. And there are several studies that used 4 or 5 mg/ml dexamethasone solution and concluded their therapeutic effect as an initial, secondary, and salvage therapy in SSNHL. Therefore, we may presume that 5 mg/ml dexamethasone solution is not considered to be a subtherapeutic concentration in the study of intratympanic steroid injection. However, as higher dexamethasone concentration may have more possibility to improve the therapeutic effect, further study with higher concentration would be needed to find the optimal treatment protocol of tinnitus. In conclusion, we believe that it may be worthwhile to conduct further studies with larger sample sizes and various treatment protocols (the concentration, number, and interval of injection) for a more convincing conclusion in the future.