Hemostatic Control with Gelatin Sponge and Quantum Molecular Resonance Coagulation in a Case of Glomus Tympanicum.

Surgical removal of tumor is the primary treatment of choice for glomus tympanicum (GT). However, because the tumor has abundant blood flow, bleeding control is crucial, and preoperative embolization may be performed. Here, we report the case of a 46-year-old female who visited our hospital with a complaint of right pulsatile tinnitus. A red pulsatile mass was found in the right tympanic cavity, and she was diagnosed with class B1 GT and subsequently underwent surgical treatment. We judged that bleeding could be controlled by intratympanic cavity manipulation alone and decided to perform transmeatal tumor resection without preoperative arterial embolization. After creating a tympanomeatal flap and performing an atticotomy, some pieces of Spongel® were inserted between the tumor and the tympanic wall. The Spongel® absorbed the blood and created a space between the tumor and tympanic wall, which allowed for the insertion of the tip of the Vesalius® handpiece to coagulate the tumor. The coagulation caused the tumor to shrink, thereby widening the space and allowing for further resection. Although the surgical manipulation caused bleeding, complete resection was achieved by the application of Spongel® and coagulation with Vesalius®. Since the tip of the Vesalius® was not burned, hemostasis was successfully achieved, and the operation proceeded while maintaining a clear field of view. There was little bleeding and no postoperative complications. The patient was discharged on the sixth postoperative day. One year after surgery, pure tone audiometry showed no change in the level of bone conduction. Spongel® and Vesalius® are useful tools that allow to safely perform surgeries even in narrow spaces such as the tympanic cavity.

Characteristics of repeated recidivism in surgical cases of cholesteatoma requiring canal wall reconstruction.

OBJECTIVE: Few reports discuss the characteristics of repeated recidivism of cholesteatoma. We describe the clinical characteristics of patients with cholesteatoma who experienced at least two recidivism episodes after initial surgery for cholesteatoma requiring canal wall reconstruction. METHODS: We reviewed the medical records of 11 patients who underwent surgery for cholesteatoma with canal wall reconstruction at our department between April 2008 and March 2018 and subsequently experienced two relapses that necessitated revision surgery involving tympanomastoidectomy with canal reconstruction. Patient age at the time of the first surgery ranged from 6 to 56 (mean, 25.7) years. Seven (63.6%) of the 11 patients were male. These 11 patients were classified according to the type of recidivism, and their characteristics (pathology, operation date, operation method, pattern of relapse, and position of recurrence) were investigated. RESULTS: Four cases involved secondary residual cholesteatoma, with the mean interval between the first revision surgery and the second revision surgery being 23.8 (range, 11-39) months. Secondary residual sites included the anterior tympanic cavity, tympanic sinus, and anterior end of the reconstructed cartilage of the canal wall. The other seven cases involved secondary recurrence, with the mean interval between the first and the second revision surgery being 26.1 (range, 12-57) months. The sites of recurrence were at the edges of the reconstructed cartilage. One notable case involved the cartilage junction, leading us to hypothesize that retraction of the temporal muscle flap and the patulous Eustachian tube was the underlying cause. CONCLUSION: For residual cholesteatoma, strict measures are necessary to maintain the operation under clear view, and more careful follow-up is necessary in patients who have had previous surgery at another hospital. For recurrent cholesteatoma, it was recognized that Eustachian tube function must be ascertained in advance, and careful observation of the reconstructed cartilage edge is necessary.

A Case of Gorham-Stout Disease Treated with Fistula Closure by Transmeatal Approach.

Gorham-Stout disease, a rare and intractable disease of unknown etiology, causes systemic bone lysis and replacement with lymphoid tissue. Here, we report a case of Gorham-Stout disease with cerebrospinal fluid leakage in a 16-year-old boy. The patient complained of nasal discharge, right ear obstruction, fever, and headache. A computed tomography scan of the head showed osteolysis around the right internal carotid artery, vestibule, and cochlea and osteolytic changes in the left parietal bone. It was suggested that the patient had bacterial meningitis owing to the leakage of cerebrospinal fluid from the fistula caused by the temporal bone osteolysis. He was treated with meropenem, and a transmeatal fistula closure and a bone biopsy of the left parietal bone were performed. Intraoperatively, osteolysis was observed on the promontory and around the internal carotid artery. The fistula was closed by dense filling and compression around the fistula, in the middle ear cavity, and in the external auditory canal. The symptoms disappeared after the surgery. Bone biopsy showed the presence of a lymphangioma, and Gorham-Stout disease was diagnosed. Prophylactic bisphosphonate therapy was initiated. A 4-year follow-up revealed no progression of the disease.

A Case of Cochlear Implantation in a Patient with Superficial Siderosis.

Superficial siderosis is a disease in which iron from hemoglobin is deposited in the central nervous system, resulting in conditions such as progressive sensorineural hearing loss, cerebellar ataxia, dementia, and pyramidal signs. A 30-year-old man with superficial siderosis received a cochlear implant in the left ear, which had shown complete hearing loss. Good auditory responses were obtained at 14 days after implantation. The postoperative average hearing level with the cochlear implant was 56.7 dB at 3 months and 55.0 dB at 6 months. However, the patient showed gradual hearing loss, and the dynamic range changed each time the electrode parameters were adjusted. To assess residual hearing ability, single-photon emission computed tomography was performed together with an assessment of electrical auditory brainstem response, which showed a good response and increased blood flow in both the temporal lobes. Based on this result, we asked the patient to continue using the cochlear implant to see whether a perception of speech response would be obtained. However, the patient discontinued using the cochlear implant because he could not hear satisfactorily. Hearing outcomes after cochlear implant surgery for patients with superficial siderosis are not necessarily good. Therefore, the possibility of unsatisfactory results should be fully explained before recommending this surgery to patients.

Clinical characteristics, the diagnostic criteria and management recommendation of otitis media with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (OMAAV) proposed by Japan Otological Society.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a form of necrotizing vasculitis with few or no immune deposits. It primarily affects small and medium blood vessels. AAV is classified into three categories, granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangitis (EGPA), and two major ANCAs, proteinase 3 (PR3)-ANCA or myeloperoxidase (MPO)-ANCA are involved in their pathogenesis. Intractable otitis media frequently occurs in patients with GPA, MPA or EGPA, although all patients show similar clinical features, regardless of the type of AAV. Furthermore, approximately 15% patients with otitis media caused by AAV do not show ANCA positivity, histopathological evidence, or any other AAV-related lesions at the initial visit; therefore, these patients do not fulfill the ordinary diagnostic criteria for systemic AAV. Thus, we first proposed that this condition could be categorized as "otitis media with AAV (OMAAV)". Subsequently, the Japanese Otological Society (JOS) conducted a nationwide survey between December 2013 and February 2014 and identified 297 patients with OMAAV. The survey revealed that OMAAV is a disease that initially occurs in the middle ear and subsequently spreads to other organs such as the lungs and kidneys, with eventual involvement of all body organs. Severe sequelae such as facial palsy, hypertrophic pachymeningitis, complete deafness, and subarachnoid hemorrhage resulting in death can also occur. In this review, we introduce the clinical features, diagnostic criteria, and treatment strategies recommended by JOS for early diagnosis and treatment of OMAAV.

A Case of Skull Base Chondrosarcoma with Intraoperative Trigemino-Cardiac Reflex.

A 75-year-old female patient presented with a suspected recurrence of a clival chordoma. The tumor was resected using the infratemporal fossa type B and anterior petrosal approach with the help of a neurosurgeon. During cauterization of the trigeminal nerve, the patient developed cardiac arrest for approximately 10 seconds because of the trigemino-cardiac reflex (TCR). After several sternal compressions, there was return of spontaneous circulation. The operation was resumed after the circulatory dynamics stabilized. Subsequently, the surgery was completed with partial resection of the tumor without the recurrence of cardiac arrest. The pathological diagnosis was chondrosarcoma, and postoperative treatment with radiotherapy was started. Stimulation of the sensory branches of the trigeminal nerve induces TCR. There are reports of TCR developing in approximately 10% of skull base surgery cases in the absence of atropine administration. We report a rare case of TCR during the surgical procedure for the treatment of a skull base chondrosarcoma.

Three Dimensional Motion Analysis of Hand Tremors During Endoscopic Ear Surgery.

BACKGROUND: Endoscopic surgery is developing in various clinical specialties. During ear endoscopic surgery, a surgeon has to hold an endoscope with one hand and operate the surgical instruments with another hand. Therefore, the stability of the surgeon's hand affects the field of surgical view and quality of the surgery considerably. There are few techniques which are used during surgery to stabilize the endoscope. However, no study has evaluated the efficacy of such techniques in detail. This study examined the three dimensional movement of an endoscope to compare and evaluate the effect of various stabilization techniques to reduce the hand tremor while using the endoscope. METHODS: A non-randomized controlled trial involving 15 medical students was conducted in Tottori University, Japan. Subjects held an endoscope with their non-dominant hand and manipulated it using three different stabilization techniques i.e. with resting the elbow on the table, resting the endoscope on the ear canal, both with the elbow on the table and endoscope on the ear canal. For the control, subjects were made to use the endoscope without any stabilization technique. The endoscopic movement was measured with and without using the stabilization techniques. RESULTS: The results obtained in this study indicated that manipulating the endoscope with resting the elbow on the table restrains both vertical (Y-axis) and optical axis (Z-axis) direction of tremor, and manipulating the endoscope by resting it on the ear canal restrains both vertical (Y-axis) and horizontal axis (X-axis) direction while the combined use of both the techniques reduces the endoscope movement in all the three X, Y and Z axes. CONCLUSION: In conclusion, concomitant use of both techniques appears to be clinically beneficial in endoscopic ear surgery.

Usefulness of High-Resolution 3D Multi-Sequences for Peripheral Facial Palsy: Differentiation Between Bell's Palsy and Ramsay Hunt Syndrome.

OBJECTIVE: To investigate the usefulness of magnetic resonance imaging (MRI) including three-dimensional (3D) sequences in the differentiation between Bell's palsy (BP) and Ramsay Hunt syndrome (RHS). STUDY DESIGN: A prospective study. SETTING: Tertiary care center. PATIENTS: Twenty patients: 15 patients with BP and five patients with RHS. INTERVENTION: Diagnostic. MAIN OUTCOME MEASURE: Clinical diagnosis (BP or RHS). RESULTS: The presence of hyperintensity on 3D-fluid-attenuated inversion recovery sequence (3D-FLAIR) and enhancement on gadolinium-enhanced (CE)-3D-FLAIR and CE-3D-T1-weighted image (3D-T1WI) along the internal auditory canal (IAC) wall were significantly associated with RHS (p < 0.05). Hyperintensity in the inner ear was observed on pre- and postcontrast 3D-FLAIR, and enhancement of the cranial nerve (CN)-VIII was observed only on CE-3D-FLAIR. The presence of these findings also showed significant relationships with RHS (p < 0.05). Moreover, thickening of the CN-VII in the fundus of the IAC in 3D-constructive interference on steady state sequence (3D-CISS) also showed a significant association with RHS (p < 0.05). In contrast, the presence of hyperintensity of the CN-VII in the fundus of the IAC on 3D-FLAIR did not demonstrate a significant relationship (p = 0.95), and enhancement in this region was observed in all cases on CE-3D-FLAIR and gadolinium-enhanced-three-dimensional-T1-weighted gradient echo sequence (CE-3D-T1WI). CONCLUSIONS: 3D MRI sequences are useful for differentiating RHS from BP. In particular, the enhancement in the CN-VIII and/or along the IAC wall are valuable findings, and CE-3D-FLAIR is the most useful sequence to evaluate these findings. Thickening of the CN-VII on 3D-CISS is also an important finding.

Sequential motion of the ossicular chain measured by laser Doppler vibrometry.

OBJECTIVE: In order to help a surgeon make the best decision, a more objective method of measuring ossicular motion is required. METHODS: A laser Doppler vibrometer was mounted on a surgical microscope. To measure ossicular chain vibrations, eight patients with cochlear implants were investigated. To assess the motions of the ossicular chain, velocities at five points were measured with tonal stimuli of 1 and 3 kHz, which yielded reproducible results. The sequential amplitude change at each point was calculated with phase shifting from the tonal stimulus. Motion of the ossicular chain was visualized from the averaged results using the graphics application. RESULTS: The head of the malleus and the body of the incus showed synchronized movement as one unit. In contrast, the stapes (incudostapedial joint and posterior crus) moved synchronously in opposite phase to the malleus and incus. The amplitudes at 1 kHz were almost twice those at 3 kHz. CONCLUSIONS: Our results show that the malleus and incus unit and the stapes move with a phase difference.

Clinical features and treatment outcomes of otitis media with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (OMAAV): A retrospective analysis of 235 patients from a nationwide survey in Japan.

OBJECTIVE: We aimed to analyze clinical features and treatment outcomes of otitis media caused by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), i.e. otitis media with AAV (OMAAV). METHODS: This survey was performed between December 2013 and February 2014. The study began with a preliminary survey to 123 otolaryngology institutions in Japan to inquire about their experiences with OMAAV patients during the past 10 years, and was followed by a questionnaire survey to investigate clinical and laboratory findings. OMAAV was defined using the criteria described in the text. RESULTS: Two hundred and thirty-five patients classified as OMAAV were enrolled in this study. They were characterized as follows: (1) disease onset with initial signs/symptoms due to intractable otitis media with effusion or granulation, which did not respond to ordinary treatments such as antibiotics and insertion of tympanic ventilation tubes, followed by progressive hearing loss; (2) predominantly female (73%) and older (median age: 68 years); (3) predominantly myeloperoxidase (MPO)-ANCA-positive (60%), followed by proteinase 3 (PR3)-ANCA-positive (19%) and both ANCAs-negative (16%); (4) frequently observed accompanying facial palsy (36%) and hypertrophic pachymeningitis (28%); and (5) disease often involving lung (35%) and kidney (26%) lesions. Four factors associated with OMAAV were found to be related to an unfavorable clinical course threatening the patient's hearing and/or lives, namely facial palsy, hypertrophic pachymeningitis, both ANCAs-negative phenotype, and disease relapse. The occurrence of hypertrophic pachymeningitis was associated with facial palsy (p < 0.05), both ANCAs-negative phenotype (p < 0.001), and headache (p < 0.001). The administration of corticosteroid together with an immunosuppressant was an independent predicting factor for lack of disease relapse (odds ratio [OR] = 1.90, p = 0.03) and an improvement in hearing loss (OR =2.58, p = 0.0002). CONCLUSION: Since OMAAV has novel clinical features, the disease may be categorized as a subentity for the classification of AAV.

Analysis of Direct Simultaneous Measurement of Glottal Airflow Velocity, Subglottal Pressure, and High-Speed Imaging Using Flexible Transnasal Endoscope in a Human Subject.

It is difficult to directly observe glottal airflow velocity just above the glottis due to sensor size requirements and limited accessibility. We developed a miniature hot-wire probe and flexible fiberscopic high-speed imaging system for human examinations. Simultaneous direct measurement of glottal airflow velocity, subglottal pressure, and vocal fold vibration was achieved in a patient who was treated with a T-tube for tracheal stenosis. Airflow velocity changes at the anterior midline of the vocal folds were synchronized with subglottal pressure changes during each phonation cycle. The velocity at the anterior midline of the vocal folds showed a rhythmic pattern of sharp, high peaks. The result of fast Fourier transform analysis indicated that glottal velocity at the anterior midline of the vocal folds had abundant high-frequency components that were not affected by resonance of the vocal tract. Airflow velocity was variable and diminished except at the anterior midline of the vocal folds.

Staged resection for vestibular schwannoma.

CONCLUSION: Surgery remains the preferred option for large vestibular schwannoma (VS). The presence of unpredictable intraoperative difficulties may convince the operator to suspend the surgery to avoid risks to patient life. Additional surgeries may be mandatory and are better performed using a transcochlear approach. High rates of complications, poor facial nerve results, and a percentage of incomplete removals should be expected in such unfavorable cases. OBJECTIVES: To review the results for nine cases of huge VS treated by staged resection. METHOD: A retrospective case review was performed for all nine patients who underwent staged resection of VS at the Gruppo Otologico between 1984-2012. The decision to perform staged surgery was always made intra-operatively after encountering unpredicted difficulties. RESULTS: The nine patients represented 0.3% of all patients who underwent VS surgery during the same period. Mean tumor size was 4.7 cm (range = 3.0-6.6 cm). Two cases required three surgeries, resulting in a total of 20 operations. In addition, two cases required pre-operative ventriculoperitoneal shunt and one required temporary tracheotomy. After the final stage of surgery, complete removal had been achieved in six of the nine patients. The facial nerve was never preserved anatomically.

Sequential multipoint motion of the tympanic membrane measured by laser Doppler vibrometry: preliminary results for normal tympanic membrane.

BACKGROUND: Numerous studies have reported sound-induced motion of the tympanic membrane (TM). To demonstrate sequential motion characteristics of the entire TM by noncontact laser Doppler vibrometry (LDV), we have investigated multipoint TM measurement. MATERIALS AND METHODS: A laser Doppler vibrometer was mounted on a surgical microscope. The velocity was measured at 33 points on the TM using noncontact LDV without any reflectors. Measurements were performed with tonal stimuli of 1, 3, and 6 kHz. Amplitudes were calculated from these measurements, and time-dependent changes in TM motion were described using a graphics application. RESULTS: TM motions were detected more clearly and stably at 1 and 3 kHz than at other frequencies. This is because the external auditory canal acted as a resonant tube near 3 kHz. TM motion displayed 1 peak at 1 kHz and 2 peaks at 3 kHz. Large amplitudes were detected in the posterosuperior quadrant (PSQ) at 1 kHz and in the PSQ and anteroinferior quadrant (AIQ) at 3 kHz. The entire TM showed synchronized movement centered on the PSQ at 1 kHz, with phase-shifting between PSQ and AIQ movement at 3 kHz. Amplitude was smaller at the umbo than at other parts. In contrast, amplitudes at high frequencies were too small and complicated to detect any obvious peaks. CONCLUSION: Sequential multipoint motion of the tympanic membrane showed that vibration characteristics of the TM differ according to the part and frequency.

Deleted in Esophageal Cancer 1(DEC1) is down-regulated and contributes to migration in head and neck squamous cell carcinoma cell lines.

BACKGROUND: Previous studies have shown that the expression of Deleted in Esophageal Cancer 1 (DEC1) is significantly reduced in esophageal squamous cell carcinoma. Patients with head and neck squamous cell carcinoma (HNSCC) often develop esophageal carcinomas. MATERIALS AND METHODS: We analyzed the expression of DEC1 and histone modifications in HNSCC cell lines. The motility and invasive ability of the HNSCC cell lines were also studied. RESULTS: Of 18 cell lines, 12 (66.7%) showed down-regulation of DEC1. Chromatin immunoprecipitation assays indicated that H3 K27 trimethylation levels in the DEC1-down-regulated cell lines were greater than that in the DEC1-expressed cell lines. Migration assays showed that the DEC1-down-regulated cell lines tended to be more motile than the DEC1-expressed cell lines. CONCLUSION: DEC1 is down-regulated and tends to contribute to the migration ability of HNSCC cell lines. In addition, H3 K27 trimethylation potentially plays an important role in the regulation of DEC1 expression.

Successful resection of posterior mediastinal thyroid cancer by partial sternotomy combined with video-assisted thoracoscopy.

We report on a rare case of substernal thyroid carcinoma extending into the posterior mediastinum of a 48-year-old man. The tumor was resected by partial sternotomy and a small anterior thoracotomy, combined with video-assisted thoracoscopy. The pathological diagnosis was of a well differentiated papillary adenocarcinoma of the thyroid with mediastinal extension. The patient had an uneventful postoperative course and no recurrence of tumor 6 months after surgical treatment. We describe this surgical approach and discuss the advantage for cervicothoracic tumors extending into the posterior mediastinum.

[Superselective intraarterial chemotherapy using low dose CBDCA and Pirarubicin with concurrent radiotherapy for head and neck cancer].

To study the effects of superselective intraarterial chemotherapy with low-dose CBDCA, Pirarubicin, and concurrent radiotherapy on head and neck cancer, we compared primary cancer response and histopathological effective grades in 66 patients (more than T2) divided into radical and preoperative radiotherapy groups. The radical group (n=33) showed a 75.7% response in primary cancer, i.e. 54.5% complete remission and 21.2% partial remission. The preoperative group (n = 33) showed 39.4% complete remission when the histopathological effective grade was higher, and 57.6% partial remission when the grade was lower. Cancer response was better in the oral cavity, mesopharynx, and hypopharynx than in the parasinus. In the preoperative group, 5-year overall survival was 84.4% when the effective grade was higher, and 29.4% when the grade was lower. Survival differed significantly (P<0.01) between higher and lower grades. Additional postoperative therapy is thus essential in patients with lower grades of histopathological effectiveness.