Reflections on Assisting Dr. Eric Wang at a Live Skull Base Surgery Demo

 作者：黃毓雯 (Yu-Wen Huang, MD.)

📸 (Photo with Dr. Wang after the live demo surgery — a memory that will keep me moving forward.)

During a recent visit from Dr. Eric Wang of the UPMC Skull Base Center, I had the opportunity to assist in a live demonstration of endoscopic skull base surgery here in Taiwan. It was a compact but deeply meaningful experience — not just for the surgical exposure, but also for what it represented: cross-institutional learning, technical refinement, and subtle moments of professional connection.

As a rhinologist practicing in Taipei Veterans General Hospital, this was actually my third year assisting Dr. Wang during his visits. This year’s case was particularly complex. In addition to the pituitary adenoma at the skull base, the patient also had bilateral sinonasal lesions, which were later confirmed as respiratory epithelial adenomatoid hamartomas (REAH).

REAH is an inflammatory lesion, which means it tends to bleed during dissection — a factor that significantly complicates visualization and maneuverability in endoscopic surgery. What made it even more challenging was the need to preserve the nasoseptal flap and its vascular pedicle during REAH removal, in order to ensure a viable reconstruction for the skull base defect later in the procedure. This demanded not just technical precision, but strategic foresight in how the steps were executed — an insight I was grateful to observe and learn from firsthand.

Outside the OR, I had a brief but kind exchange with Dr. Wang about my current academic path. I shared with him that I had applied to MD Anderson for a research fellowship but hadn’t heard back yet. He was encouraging and supportive — something that meant a lot at that moment.

That simple encouragement, combined with the surgical exposure, reignited a part of me that had started to dull in the routine of daily hospital life. It reminded me why I continue to do this — not just for the surgery itself, but for the conversations, the learning, and the professional growth that comes from these moments of intersection.

與世界級顱底手術專家的同台學習心得

作者：黃毓雯

📸（手術後與 Dr. Wang 合照 —— 一張會陪我繼續前行的照片）

最近，美國匹茲堡大學醫學中心（UPMC）顱底中心的 Dr. Eric Wang 來台參與一場現場示範手術（Live Demo），我有幸作為助手參與這場手術。這段時間雖然短暫，卻帶來了非常深刻的啟發 —— 不只是技術上的提升，更是專業交流與職涯省思的火花。

身為台北榮總的鼻科醫師，這是我第三年擔任 Dr. Wang 來台手術的助手。今年的案例比以往更具挑戰性：除了顱底的腦下垂體腫瘤（pituitary adenoma）需要處理外，病人同時合併雙側鼻竇病灶，術後病理證實為嗅覺上皮呼吸性腺瘤樣增生（REAH）。

REAH 本身是發炎性病灶，因此在清除過程中容易出血，這對於內視鏡下操作的視野與辨識造成極大挑戰。而更困難的是，在處理 REAH 的同時，還必須同時保留 nasoseptal flap（鼻中膈黏膜瓣）與其血管蒂（pedicle）的完整性，以利後續顱底重建的進行。這讓整體手術的策略規劃與步驟安排都必須更細膩、緊密，也讓我對鼻竇及顱底手術的手術美學與決策邏輯有更深一層的體會。

術後，我也和 Dr. Wang 有了簡短但溫暖的交流。我提到自己近期申請國外的研究進修機會，但尚未收到回覆。他非常鼓勵我，並表示如果後續仍沒有消息，可以再聯繫他看看是否能幫忙。

這樣一段小小的對話，其實給我很大的力量。它提醒我：除了日常繁忙的臨床工作，這條路上其實還有很多人願意給予支持；也提醒我，持續精進與堅持自我信念，是我當初選擇醫師這條路的初衷之一。

感謝有機會參與這場交流手術，也更堅定我要在鼻科與顱底手術這條路上，走出自己的風格與價值。

 

反覆性急性鼻竇炎

 作者：黃毓雯

鼻竇炎若是按照症狀持續的時間或是發作的頻率，可以分成急性鼻竇炎、慢性鼻竇炎、反覆性急性鼻竇炎。

反覆性急性鼻竇炎的定義

反覆性急性鼻竇炎（Recurrent Acute Rhinosinusitis, RARS）為：

＞　一年內發作至少四次急性鼻竇炎，

＞　每次發作症狀持續少於四週，

＞　發作之間症狀完全緩解。

歐洲鼻科醫學會鼻竇炎指引(EPOS 2020)指出，診斷反覆性鼻竇炎時候，至少要有一次，當急性發作時，藉由內視鏡檢查或是鼻竇電腦斷層證實是急性鼻竇炎，不能僅由症狀推測。

換句話說，多數反覆性鼻竇炎的病人，在非發作期間，客觀的檢查（內視鏡或是影像檢查）可能是完全正常。

甚麼情形較容易產生反覆性鼻竇炎呢？　

臨床上出現反覆鼻塞、黃膿鼻涕、面部脹痛的病人，必須高度警覺潛藏的其他病因。

這些病因直接或是間接影響鼻腔黏膜排鼻涕的功能，影響鼻竇通氣與排氣。

EPOS 2020 討論的潛在病因簡列如下：　

＞　環境的暴露（潮濕、黴菌、空氣污染、氣候變遷）

＞　吸菸（主動吸菸或是被動二手菸）

＞　免疫缺陷（特定的免疫系統疾病造成鼻腔黏膜功能異常）

＞　鼻竇結構異常導致於鼻蓄膿容易積累在鼻竇

回顧看診經驗，時不時會遇到病患拿轉診單來，主訴：

「醫師，我最近三個月裡已經感冒三次了，每次鼻塞、黃鼻涕，一個星期後才慢慢好起來。這次又感冒了，診所醫師說我已經吃到沒有藥可以吃了啦 😷😷😷」

第一步，先藉由重點性問診釐清病患口中的＂感冒＂，到底是不是鼻竇炎之外，接著，做內視鏡檢查或是影像的檢查，檢查的目的就在於：確認病患當下鼻內是否有黃膿鼻涕？鼻腔裡是否有鼻竇結構異常？甚至有時候會發現，其實是腫瘤在鼻子裡？

在這裡補充這邊提到的結構異常，有些是內視鏡下就可觀察的，有些需要藉由電腦斷層：

👉　鼻中膈彎曲。其實不少見。內視鏡下能看到突出的鼻中膈骨性結構導致鼻竇開口狹窄。

👉　鼻竇異常的氣化。這部分需要藉由電腦斷層看出，也是間接導致膿鼻涕不容易引流。

還有一些我認為臨床上常見，且需要釐清的潛在病因，在EPOS 2020沒特別強調:

👊　潛藏的黴菌感染。這類感染是單靠抗生素治療是沒有辦法痊癒的，屬於手術性的問題。

👊　潛藏的腫瘤。腫瘤如果長在鼻竇內，初期可能只表現鼻涕裡有血絲，或是膿鼻涕。

👊　牙齒問題引起的。牙齒根部感染（如牙根尖膿瘍、牙齦膿瘍）可直接波及上頷竇，引起反覆性上頷竇炎，需牙科合作評估。

大家要注意，上述的病因，真的沒辦法藉由一次的看診、檢查，就能得到答案的。需要適當的治療＋持續觀察，才能釐清問題。

治療　

藥物治療是有必要的，然後在兩次三次甚或四次的追蹤下，如果還是沒有完全康復或是高度懷疑單側鼻竇問題，就會考慮後續檢查甚或考慮手術。

👉初步處理：　

＞　有細菌感染的指標，給予短期口服抗生素。

＞　化痰藥、鼻腔沖洗：目的是稀釋膿鼻涕、清潔分泌物、降低黏膜水腫

👋👋👋若出現以下情況，不要每次都買成藥自行處理，早點尋求耳鼻喉科醫師進一步診治：

＞　一年內三次以上鼻竇炎發作

＞　每次發作症狀嚴重且恢復緩慢

＞　單側鼻塞、血涕、持續面部疼痛等可疑警訊

＞　合併牙痛、口腔異味、齒源性感染風險

＞　有既往免疫功能異常病史

最後題外話：病人很愛在出診間前，多問一題很難的問題😅

「黃醫師，那那阿我過敏很嚴重，是不是造成我一直感冒的原因？」

好問題，關於過敏是否是急性鼻竇炎（ARS）好發的危險因子，目前在文獻上仍存在不少爭議。一些研究支持過敏與急性鼻竇炎有關，但也有研究未能證實此關聯性。所以我只能說，現有的研究顯示，過敏性鼻炎並不是急性鼻竇炎發生的重要危險因子。

# 過敏與慢性鼻竇炎之間的關係

Understanding Postnasal Drip

YU-WEN HUANG, MD. 

Nasal Physiology and the Role of Mucus

The nasal cavity serves multiple physiological functions beyond respiration:

• Airflow Conduction – It provides a conduit for inspired air.

• Air Conditioning – The mucosa warms and humidifies the air via an extensive vascular network.

• Filtration – Cilia, mucus, and nasal hairs trap inhaled pathogens and particulates.

• Olfaction – The upper nasal cavity contains olfactory receptors responsible for smell.

Under normal conditions, the nasal and paranasal sinus mucosa produce approximately 1 liter of mucus per day, primarily via goblet cells and submucosal glands. This mucus is transported posteriorly by coordinated ciliary motion in a process known as mucociliary clearance, ultimately being swallowed unconsciously.

Clinical Manifestations of Postnasal Drip

Postnasal drip occurs when mucus becomes excessively thick, voluminous, or poorly drained, accumulating in the nasopharynx and trickling down into the oropharynx. This may result in:

• Throat clearing and globus sensation

• Persistent, non-productive cough

• Morning or nocturnal cough exacerbation

• Hoarseness or dysphonia

• Halitosis and nausea

• Excessive swallowing or need to expectorate mucus

Notably, elderly patients or those with chronic rhinitis may present with throat symptoms alone, without overt nasal obstruction or rhinorrhea.

Etiological Factors

Postnasal drip is not a singular disease but a clinical syndrome secondary to various underlying conditions. It generally involves mucus overproduction, altered viscosity, or impaired clearance.

🔹 Primary Causes

1. Allergic Rhinitis – Exposure to allergens (e.g., pollen, dust mites, animal dander) elicits IgE-mediated inflammation and increases serous nasal secretions.
   
   
2. Viral Upper Respiratory Infections – Induce mucosal edema and hypersecretion, sometimes blocking sinus.
   
   
3. Environmental Factors – Dry, cold air may trigger reactive mucus production. 
   
   
4. Anatomical Variations – Septal deviation or nasal polyps impair normal drainage pathways.

🔸 Secondary or Contributing Conditions

1. Gastroesophageal reflux disease (GERD)
   
   
2. Pregnancy-related rhinitis
   
   
3. Exposure to irritants (smoke, pollution, chemicals)
   
   
4. Certain medications (ACE inhibitors, hormonal therapies)
   
   
5. Chronic pulmonary conditions (COPD, asthma)
   
   
6. Enlarged adenoids or chronic adenoiditis in children
   
   
7. Spicy food and hot beverages – transiently increase secretion via autonomic stimulation

Management Principles

Management of postnasal drip is aimed at reducing secretion, improving mucociliary clearance, and minimizing inflammatory stimuli. Empiric therapy may include:

• Antihistamines (especially second-generation agents for fewer sedative effects)

• Mucolytics or expectorants

• Intranasal corticosteroids

• Antihistamine or corticosteroid nasal sprays

• Saline nasal irrigation

• Supportive care – increased hydration, environmental control, head-of-bed elevation during sleep

When to Seek Specialist Evaluation

Referral to an otolaryngologist is advised when the following are observed:

• Purulent, foul-smelling, or blood-streaked nasal discharge

• Associated fever, facial pressure, or orbital discomfort

• Persistent hoarseness, globus sensation, or dysphagia

• Unilateral nasal obstruction or anosmia

• Refractory symptoms despite appropriate medical therapy

Such features may indicate conditions requiring endoscopic examination or imaging, such as sinonasal neoplasms, nasal polyposis, deviated septum, or other significant ENT pathologies.

鼻涕倒流是怎麼回事？

作者: 黃毓雯

「醫師，我感冒很久了都沒有好，喉嚨總是卡卡的，早上起來就一直咳，感覺鼻涕都流到喉嚨了！」

這樣的情形在耳鼻喉科門診中非常常見。許多患者咳嗽持續數週甚至數月，有些人甚至咳到胸口痛、或因反覆用力而發生滲尿，但檢查胸部 X 光、肺功能都無異常，吃止咳藥也沒有效果。真正的原因，往往是＂鼻涕倒流（postnasal drip）＂引起的慢性刺激所致。

🚨什麼是鼻涕倒流？(What is Postnasal Drip?)

鼻子不只是拿來呼吸而已，它其實有多種重要的生理功能，包括：

1. 呼吸氣流通道：是空氣進入肺部的第一站

2. 加溫與加濕空氣：鼻黏膜內有豐富血管，可將乾冷空氣調節為濕暖氣體

3. 過濾異物與病原：鼻毛與黏液能阻擋灰塵、花粉、細菌等外來物質

4. 嗅覺感知：鼻腔上半區域分布嗅覺神經，負責氣味辨識

鼻腔與鼻竇每天會自然產生大量黏液（鼻涕），正常人每日分泌量約 1 公升，大部分會經由鼻咽部自然吞下，是身體清除異物與保持濕潤的重要防禦機制。

💁醫師筆記：鼻腔黏液的來源與功能

1. 黏液由鼻腔與鼻竇上皮的杯狀細胞與腺體產生與纖毛的協同作用形成「纖毛黏液清除機制（mucociliary clearance）」

2. 平均清除速度為每分鐘約 5–20 公釐

3. 正常情況下，黏液應為透明、稀薄，異常情況下則會增加量、濃度或變色

當這些分泌物過多或太濃稠，就可能在鼻咽部積聚並順勢倒流到咽喉後方，產生我們所說的鼻涕倒流（postnasal drip）。這可能導致：

1. 喉嚨卡痰或異物感

2. 清喉嚨頻繁

3. 慢性刺激性咳嗽

4. 聲音沙啞或喉嚨痛

5. 噁心、口臭等症狀

平時這些黏液會不知不覺被吞下，但在過敏、感染、乾燥氣候、黏膜退化等情況下，分泌物變得明顯，進而產生臨床症狀。

🚨鼻涕倒流的常見症狀

鼻涕倒流不僅讓人感覺不適，還常常是慢性咳嗽與喉部問題的幕後主因。以下是常見的臨床症狀：

1. 喉嚨痛或喉嚨刺癢：黏液刺激咽喉黏膜，造成慢性發炎或腫脹感

2. 頻繁清喉嚨：反覆有黏稠分泌物流下，讓人忍不住想清喉或咳嗽

3. 晚間咳嗽加劇：平躺時分泌物積聚於咽喉後方，清晨與夜間咳嗽最為明顯

4. 聲音沙啞：若分泌物接觸聲帶，可能造成聲音粗啞或疲勞感

5. 口臭與噁心：黏液倒流至胃部，部分患者會感到反胃或嘴巴有異味

6. 過度吞嚥或吐黏液：患者會意識到黏液的存在，試圖不斷咳出或吞下

這些症狀可能單獨出現，也可能混合存在。特別是在高齡族群或有慢性鼻炎病史者身上，即使沒有「鼻塞」、「黃鼻涕」等典型鼻部症狀，仍可能以單純的喉部不適或咳嗽為主要表現。

🚨鼻涕倒流的常見原因是什麼？

鼻涕倒流的成因很多，但共通點是「黏液分泌過多」、「變得太黏稠」或「排出受阻」。常見的原因包括：

常見成因分類：

1. 過敏性鼻炎（Allergic rhinitis）

當身體接觸到花粉、塵?、動物毛髮等過敏原時，會刺激免疫反應，分泌大量清水鼻涕，是鼻涕倒流最常見的原因之一。

2. 病毒感染（如感冒、鼻竇炎、流感）

病毒會刺激鼻黏膜發炎與腫脹，使分泌物變多變濃，甚至堵塞鼻竇開口，造成鼻涕積聚與倒流。

3. 氣候與空氣變化

乾冷的空氣會使鼻腔乾燥、刺激性增加，導致身體「反應性」分泌更多黏液保濕，加劇鼻涕倒流。

4. 鼻結構異常（如鼻中膈彎曲、鼻息肉）

這些結構問題會造成鼻腔內引流不順，黏液易堆積並倒流至咽喉。

其他容易被忽略的原因：

1. 辛辣食物或熱飲：刺激交感神經，短時間內增加鼻液分泌

2. 懷孕：體內雌激素上升與血流量增加會讓鼻黏膜腫脹、黏液變多，產生「妊娠性鼻炎」

3. 胃食道逆流：可合併喉部刺激與清晨咳嗽，部分患者與鼻涕倒流症狀重疊

4. 化學刺激物：如香水、清潔劑、空氣污染、二手煙

5. 慢性呼吸道疾病（如 慢性阻塞性肺病、氣喘）：常伴隨上呼吸道分泌異常

6. 特定藥物：如降血壓藥（ACE inhibitors）、避孕藥、部分鎮靜劑或抗焦慮藥

7. 腺樣體肥大或慢性腺樣體炎（尤其在兒童）

🚨怎麼處理鼻涕倒流？什麼時候該就醫？

鼻涕倒流大多可透過居家照護與常見藥物控制。治療原則包括：「減少分泌物、改善排出、避免刺激」。藥物常見的治療選項包括抗組織胺、化痰藥、類固醇或是抗組織胺鼻噴劑與生理食鹽水洗鼻，可幫助減少分泌物與鼻塞；平時多喝水、避免刺激物、睡覺時抬高頭部，也有助於舒緩鼻涕倒流造成的不適。鼻涕倒流雖常見，但若症狀持續、反覆，或合併其他警訊，建議就醫找出真正的原因。

🚩🚩🚩以下情況，建議諮詢耳鼻喉科醫師進一步檢查：

👉鼻涕顏色變黃或變綠、混有膿性或異味

👉分泌物有明顯惡臭或夾帶血絲

👉合併發燒、頭痛、臉部悶脹或眼窩不適

👉咳嗽或喉嚨不適超過 10 天仍未改善

👉聲音沙啞持續、喉嚨有異物感或吞嚥困難

👉合併單側鼻塞、單側流鼻涕或嗅覺異常

這些可能代表有細菌感染、鼻竇炎、鼻息肉、鼻中膈彎曲，或其他需要專科介入的情況。

Why Do I Sneeze Every Morning After Waking Up?

— Understanding Allergic Rhinitis, One of the Most Common Nasal Conditions

Yu Wen Huang, MD. 

Do you often wake up sneezing, with a runny or congested nose and itching in your nose or eyes? If these symptoms occur regularly, especially in the early morning, they may indicate a condition known as allergic rhinitis.

1. What Is Allergic Rhinitis, and Why Do Symptoms Appear So Quickly?

Allergic rhinitis is a common condition in which the body’s immune system reacts excessively to harmless substances such as dust mites, pollen, pet dander, or mold. When these allergens enter the nasal cavity, they trigger the release of histamine and other inflammatory mediators, resulting in a range of symptoms.

• Sneezing 👈 stimulation of sensory nerve endings
• Runny nose 👈 increased mucus gland secretion in the nasal lining
• Nasal congestion 👈 swelling of the nasal mucosa and blood vessel dilation
• Itchy nose and eyes 👈 irritation caused by inflammatory substances

Symptoms are often worse in the early morning, due to prolonged nighttime exposure to allergens (like dust mites in bedding), combined with changes in autonomic nervous system activity. Some studies also show that immune cells related to allergy responses are more active in the morning, intensifying symptoms.

2. Classification: Seasonal vs. Perennial Rhinitis, and Symptom Severity

Allergic rhinitis is typically categorized into two types:

• Seasonal allergic rhinitis (hay fever): triggered by pollen during specific seasons (e.g., spring)
• Perennial allergic rhinitis: symptoms persist throughout the year, commonly due to indoor allergens

In Taiwan, perennial allergic rhinitis is more prevalent, as the humid subtropical climate supports the growth of dust mites and molds.

Symptom severity can also be classified as:

• Mild/intermittent: symptoms occur occasionally and do not interfere with daily life
• Moderate-to-severe/persistent: symptoms are frequent, and may affect sleep, concentration, or quality of life

3. Do I Need an Allergy Test?

Many patients ask whether allergy testing is necessary. However, it is important to understand that testing is not always required for diagnosis.

Blood tests (such as serum IgE or MAST) may not fully reflect clinical symptoms, especially in adults. Some individuals with typical allergic symptoms may test negative, while others with positive test results may not experience symptoms in daily life.

Testing may be considered in the following situations:

• Symptoms appear linked to specific environmental exposures or seasons
• There is coexisting asthma, eczema, or allergic conjunctivitis
• Family history of allergies, particularly in children
• Considering allergen immunotherapy (e.g., dust mite desensitization)
• Results may help guide environmental or lifestyle adjustments

In Taiwan, eligibility for insurance-covered testing depends on clinical judgment and criteria (e.g., IgE levels, symptom severity). Testing can be helpful in selected cases, but it is not universally necessary.

4. Why Don’t Antihistamines Work for Everyone?

Antihistamines are effective for relieving sneezing, runny nose, and nasal itching, all of which are primarily mediated by histamine. However, they are usually less effective for nasal congestion, which is caused by blood vessel swelling and inflammation.

For patients with predominant congestion, doctors often recommend a topical steroid nasal spray or combination therapy to reduce inflammation more effectively.

Additionally, not all cases of rhinitis are caused by classical allergies. Some patients may have non-allergic rhinitis or chronic sinusitis, which require different treatment strategies.

A future article will provide an overview of available treatment options, including medications and immunotherapy.

5. Timely Treatment Can Significantly Improve Your Quality of Life

Frequent sneezing, nasal congestion, or a runny nose every morning should not be ignored. With appropriate evaluation and personalized treatment, most patients with allergic rhinitis can achieve excellent symptom control and a better quality of life.

If you are experiencing these symptoms—whether you have lived in Taiwan long-term or recently relocated— it may be time to consult an ENT specialist. A careful assessment can help identify the root cause and guide you toward effective, evidence-based care.

ENT in English

👋 Welcome to ENT in English

This page is for English-speaking patients living in Taiwan who are seeking help with long-term nasal or sinus issues.

If you're dealing with allergies, postnasal drip, or chronic nasal blockage that doesn’t improve with simple treatments, you're not alone. This site is here to help you understand your symptoms and treatment options — from daily care to when surgery might be the next step.

🩺 Let’s breathe better, understand more, and take control of your ENT health — together.

👩‍⚕️ About Dr. Huang

Dr. Yuwen Huang is a board-certified ENT specialist at Taipei Veterans General Hospital (VGHTPE) in Taipei.

She specializes in nasal and head & neck conditions, including:

• Nasal allergies and sinus infection 
• Nasal and sinus surgery
• Tear duct surgery (endoscopic DCR)
• Nasal and sinus tumors

🏥 How to Visit

Dr. Huang sees patients at the ENT Department of VGHTPE.

What to bring:

• NHI card (if available)
• Passport or ARC
• Medical records (optional)

Booking: Walk-ins accepted, but appointments are recommended. English assistance may be limited — bringing a translator is helpful.

🏥 About Taipei Veterans General Hospital (VGHTPE)

Taipei Veterans General Hospital (VGHTPE) is one of Taiwan’s leading medical centers, located in Beitou District, Taipei. It is well known for advanced care, research, and teaching, and serves both local and international patients.

The Department of Otolaryngology (ENT) provides specialized care for ear, nose, and throat conditions — including nasal allergies, sinus disease, tear duct problems, and tumors of the nose and sinuses.

Dr. Huang sees patients at the ENT outpatient clinic of VGHTPE. For her clinic schedule and appointment information, please visit:

🔗 Click here to view Dr. Huang’s clinic schedule on VGHTPE website

📍 Address: No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan
🚉 Nearest MRT: Shipai Station (Red Line), then 10-minute walk or short bus ride

📘 ENT Health Articles

👉 Why Do I Sneeze Every Morning After Waking Up?

👉 Understanding Postnasal Drip