[A Clinical Study of Acute Epiglottitis].

We carried out a retrospective review of 285 cases of acute epiglottitis (180 males, 105 females, mean age 49.6 years) that required inpatients hospital care between 1998 and 2014. All the patients complained of sore throat, and 62 patients complained of respiratory discomfort; 17 patients had severe dyspnea, and 27 patients required airway management (tracheotomy in 25, cricothyroidotomy in 2 patients). All the patients survived. As acute epiglottitis can cause rapidly progressive airway obstruction and death, emergent airway management should be undertaken in patients with dyspnea. However, it is difficult to determine the indications for prophylactic respiratory management in patients without dyspnea. Therefore, the disease severity of the epiglottitis was evaluated on a five-grade scale according to the degree of swelling of both the epiglottis and the arytenoids. Although prospective evaluation is necessary, this scoring system may be beneficial to determine the indication for airway management, because all of the patients who complained of severe dyspnea or underwent airway management had grade 4 or 5 disease, while none of the patients with grade 1-3 disease required tracheotomy or cricothyroidotomy. Moreover, we compared the white blood cell count, body temperature, serum CRP and the interval from the onset between the group that required airway management and the group that did not require airway management. The white blood-cell count and body temperature were significantly higher, and the interval from the onset was significantly shorter in the group that required airway management than in the group that did not require airway management; however, the serum CRP level did not differ between the two groups.

Oral frostbite due to dry ice.

OBJECTIVES: Dry ice is a commercially available cryogen that is used worldwide. It may cause frostbite if misused. However, frostbite of the oral cavity due to dry ice has not been previously reported. Here, we describe the first case of dry ice-induced frostbite of the oral cavity. METHODS: We present a case of oral frostbite due to dry ice and subsequent swelling of the submandibular area and lower lip. We discuss the clinical features of oral frostbite due to volatile substance abuse. RESULTS: Oral frostbite not only may result in the impairment of the affected mucosae directly, but also may adversely affect the tissues in the vicinity of the oral cavity floor indirectly. Oral frostbite may cause edema of the upper airway tract. In case of severe pharyngolaryngeal edema, either tracheal intubation or tracheostomy is necessary. Steroids and antibiotics may be effective in preventing the development of pharyngolaryngeal edema. CONCLUSIONS: It is important to bear in mind that volatile substance abuse may possibly induce unusual events. In particular, special attention should be paid to delayed unusual events.

New Modified Transoral Approach to Remove a Hilar Stone of the Submandibular Gland: A Case Report.

Nerve damage and intraoperative bleeding for the removal of the hilar stones are possible. We used the new modified lateral oral floor approach with a 2-3 cm longitudinal mucosal incision outside of the Wharton's. There were no complications and our technique seemed to be effective.

Quantitative image analysis of nuclear chromatin distribution for cytological diagnosis.

OBJECTIVE: We previously reported on the classification of the nuclear chromatin distribution into 3 types, that is peripheral (P), mixed (M) and central (C), which were related to the malignancy of cervical glandular lesions. However, the classification was subjective as it was performed by visual assessment. In the present study, quantitative assessment of nuclear chromatin distribution using image analysis by computer was applied for objective classification of cervical squamous epithelial lesions, which are the most common cervical lesions. STUDY DESIGN: A total of 130 cells (44 cells of type P, 78 of type M and 8 of type C) from cytological specimens of cervical squamous epithelial lesions (dysplasia, squamous cell carcinoma) were analyzed. An image analysis program was developed as a plug-in macro program of an existing image processing software. The radial distribution (RD) value, which represents the gradient of the staining intensity from the center to the edge of a nucleus, was defined as an index of the chromatin distribution. RESULTS: The RD values calculated in type P, type M and type C cells showed significant statistical differences as assessed by the t test (p < 0.001). CONCLUSIONS: Quantification of the nuclear chromatin distribution by image analysis is fast and highly objective. The RD value could be useful as an index for malignancy.

Effects of External Auditory Meatus Occlusion on Ocular Vestibular Evoked Myogenic Potentials Induced by Bone Conducted Sound.

To facilitate more reliable recordings of the ocular vestibular evoked myogenic potentials (oVEMP) induced by bone-conducted sound using the B81 bone conduction transducer, we preliminarily studied the effects of external auditory meatus occlusion using an earplug on such oVEMP. Eight healthy volunteers (four males and four females, 26-48 years of age, mean age: 34. 5 years) and 14 patients with vestibular disease (2 males and 12 females, 18-59 years of age, mean age: 41.5 years) were enrolled. oVEMP testing was performed using a B81 placed on the temple. Tone bursts (500 Hz, rise/fall time: 2 ms, plateau time: 2 ms, and 70 dB nHL) were presented at a rate of 5.1 Hz. N1-P1 amplitudes were measured and analyzed. Occlusion resulted in significantly larger N1-P1 amplitudes [mean ± SE (SD): 12.3 ± 1.67 (6.71) µV vs. 9.55 ± 1.55 (6.21) µV; p = 0.020, paired t-test]. While four patients did not exhibit any response on either side in the absence of occlusion, all of them showed unilateral or bilateral responses when occlusion was employed. In any patient occlusion did not result in loss of oVEMP responses. External auditory meatus occlusion using an earplug could allow more reliable recordings of bone conduction transducer-induced oVEMP.

Congenital External Auditory Canal Cholesteatoma Resected by a Transcanal Endoscopic Approach.

OBJECTIVE: To describe the first case of congenital external auditory canal cholesteatoma resected via a transcanal endoscopic approach and describe the possible pathologenesis of cholesteatoma. PATIENT: A 2-year-old female patient presented with a cholesteatoma that extended from the floor of the external auditory bony canal to the inferior quadrant of her right tympanic membrane. INTERVENTION: Otological examinations and computed tomography were performed. The cholesteatoma was resected using a transcanal endoscopic approach. RESULTS: Pathologic examination confirmed the diagnosis of external auditory canal cholesteatoma. The patient's postoperative hearing was observed to be normal. Cholesteatoma did not recur during the 2-year follow-up period. Computed tomography scan revealed an isodense mass, partly surrounded by bony tissue, on the floor of the external auditory canal, outside of the inferior quadrant of an intact tympanic membrane. A minor malformation of the bony tissue, covering the inferiolateral surface of the cholesteatoma, was observed. The proposed mechanisms of pathogenesis are: 1) the embryonic developmental deficits of the meatal plug, during its differentiation into squamous epithelium, cause the arrest of ectodermal tissues, 2) a remnant of the squamous epithelium becomes trapped in the niche of the foramen tympanicum. CONCLUSION: A rare case of congenital external auditory canal cholesteatoma, located on the inferior external auditory canal, was diagnosed and resected using a transcanal endoscopic approach. It was possibly caused by a minor anomaly of the first branchial cleft or by a remnant of the squamous epithelium trapped in the foramen tympanicum.

Multifactorial analysis of local control and survival in patients with early glottic cancer.

OBJECTIVES: The purpose of this study is to determine the effects of various prognostic factors for early glottic cancer patients who underwent radiotherapy. METHODS: We retrospectively reviewed the all patients who were treated at our hospital for early glottic squamous cell carcinoma from 2004 to 2016. Data included patient's age, sex, T classification, tumor size, pathological grade, anterior commissure involvement, subglottic extension, laryngeal ventricle involvement, and restriction of vocal cord movement. RESULTS: There were 74 patients with T1 tumors and 31 with T2 tumors. Recurrence was found in four patients with T1 and eight patients with T2. There were 99 males and six females enrolled, and the mean age was 67.5 ± 9.2 years for T1a, 67.3 ± 11.2 years for T1b, and 67.4 ± 7.9 years for T2. One patient with recurrence after 1 month was thought to have a residual tumor. The 5-year overall survival (OS) rate and the 5-year disease-specific survival (DSS) rate for T1-T2 patients were both 100%. The rate of larynx preservation was 94.6% for T1 and 74.2% for T2. A univariate analysis showed that the effective factors were age, T, size, SE. A multivariate logistic regression analysis showed that age influenced the recurrence status. Size is also suspected to be a prognostic factor. CONCLUSIONS: This study revealed that the effective factors were age, T, size, and SE. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1701-1706, 2020.

Sinonasal Inverted Papilloma: Efficacy of Demucosation to Reduce Recurrence After Surgical Managements.

To compare the outcomes of various surgical approaches to resect sinonasal inverted papilloma and to discuss their advantages and disadvantages. A retrospective chart review of 61 consecutive patients with sinonasal inverted papilloma was performed. Surgical treatment included non-demucosation endoscopic sinus surgery (ESS), demucosation ESS, endonasal medial maxillectomy (EMM), Draf type 3, Caldwell-Luc surgery, Denker, Killian, and lateral rhinotomy. Recurrence rates were compared between endonasal and external approaches and between demucosation and non-demucosation. After the first curative surgery, the non-demucosation ESS, endonasal demucosation (demucosation ESS, EMM, and Draf type 3), and external surgery showed recurrence rates of 61.5%, (8/13), 0.0% (0/21), and 7.4% (2/27), respectively. A significantly lower recurrence rate was observed in the endonasal demucosation (p < 0.001) and in the demucosation ESS group (p < 0.001) in comparison with the non-demucosation ESS. However, as for recurrence rate, no statistically significant difference was observed between endonasal surgery and external surgery (p = 0.162). Demucosation is a better strategy for the treatment of inverted papilloma than is non-demucosation. Demucosation is the key procedure for preventing recurrence.

A Small Glomus Tympanicum Tumor Resected by Minimally Invasive Transcanal Endoscopic Approach.

We present a case of the transcanal endoscopic resection of a glomus tympanicum tumor. A 51-year-old woman presented with pulsatile tinnitus of the right ear persisting for 6 months. A reddish mass was observed through her tympanic membrane. A computed tomography scan revealed a small mass in the mesotympanum. She was diagnosed with a right-sided glomus tympanicum tumor. The glomus tympanicum tumor was classified as type 1 using the Glasscock-Jackson classification, class A using the Fisch classification, and class A1 using the modified Fisch and Mattox classification. The tumor was transcanally and completely resected by endoscopy without any complication. Before and after the surgery, pure-tone audiometry showed a normal hearing level. Preoperative right-sided pulsatile tinnitus resolved after the surgery. Transcanal endoscopic ear surgery is a favorable surgical method for small localized glomus tympanicum tumors.

Apocrine Adenoma of the External Auditory Canal with Pseudoepitheliomatous Hyperplasia.

The tumors derived of the ceruminous gland in the external auditory canal are rare. Here, we report a case of a ceruminous adenoma (apocrine adenoma) with refractory chronic inflammation in the external auditory canal. A 46-year-old man presented with otorrhea, itching, and a foreign body sensation in his right ear. A soft reddish protruding lesion was revealed at the posterosuperior portion of the entry to the right external auditory canal by otoscopy. The skin lesion was endaurally resected; histopathology showed luminal structures in the middle to deep layer of the epidermis and inflammatory granulation below pseudoepitheliomatous hyperplasia. The walls of the luminal structures consisted of inner luminal secretory cells featuring apical decapitation secretion and outer myoepithelial cells. The patient was diagnosed with an apocrine adenoma. Three years after surgery, there has been no evidence of recurrence. Complete resection, including the deep layer of the epidermis, is necessary.

Endoscopic Type 1 Tympanoplasty in Chronic Otitis Media: Comparative Study with a Postauricular Microscopic Approach.

OBJECTIVE: To compare surgical outcomes after tympanoplasty without ossiculoplasty for chronic otitis media between transcanal endoscopic ear surgery (TEES) and postauricular microscopic ear surgery (PAMES). STUDY DESIGN: Case-control study. SETTING: Tertiary care university hospital. SUBJECTS AND METHODS: Consecutive patients (N = 122) who had undergone tympanoplasty without ossiculoplasty for chronic otitis media were enrolled in this retrospective study and divided into 2 groups: TEES (n = 47) and PAMES (n = 75). Middle ear condition was graded with the middle ear risk index. Hearing, repair of tympanic membrane perforation, and surgical time were assessed. RESULTS: The surgical success rate for hearing (air-bone gap ≤20 dB) was 95.7% in the TEES group and 84.0% in the PAMES group. Lower middle ear risk resulted in similar mean (95% CI) closure of air-bone gaps (TEES: 9.6, 6.5-12.6; PAMES: 8.0, 6.4-9.7; P = .333), whereas higher middle ear risk demonstrated significantly larger closure of air-bone gaps for the TEES group (10.1, 3.3-16.9) than the PAMES group (-0.2, -4.5 to 4.2; P = .009). The surgical success rate for repair of tympanic membrane perforation and surgical time were equivalent between TEES and PAMES. CONCLUSION: Under favorable conditions of the middle ear, TEES and PAMES resulted in similar hearing improvement by tympanoplasty without ossiculoplasty. However, under adverse conditions of the middle ear, TEES was a more beneficial approach for hearing improvement than PAMES.

The clinical significance of modifying X-ray tube current-time product based on prior image deviation index for digital radiography.

PURPOSE: The absorbed dose at the image receptor in digital X-ray systems increases with an incorrect adjustment of the X-ray tube current-time product (mAs). Accordingly, the exposure index, target exposure index, and deviation index (DI) are proposed as absorbed dose optimization tools. We aimed at reducing the variation of DI in a short period by employing the mAs value determined by previously used mAs and DI. METHODS: We developed software that automatically calculates mAs for subsequent X-ray examinations based on mAs and DI values from prior examinations. Portable chest X-ray examinations in an intensive care unit (ICU) were performed for 16 weeks. The software was not used for the first 10 weeks in 406 cases and was used for the remaining 6 weeks in 216 cases. The changes in the non-conformance rate of DI for 16 weeks were evaluated using the p-chart used for quality control. The effect of the software on image noise was also evaluated. RESULTS: In total, 42% of cases had a DI range of -1 to 1 without using the software; this increased to 81% when using the software. Averages and variances of DI in cases with and without the software demonstrated statistically significant differences. From the p-chart, the non-conformance rate of DI was shown to decrease when using software. The software also worked for reducing the variation in image noise. CONCLUSIONS: Our method reduced the variation in DI in a short period of time.

Evaluation of mouthpiece fixation devices for head and neck radiotherapy patients fabricated in PolyJet photopolymer by a 3D printer.

PURPOSE: The purpose of our study was to evaluate the usefulness of a biocompatible class VI resin PolyJet photopolymer Objet MED610 (MED610)-made mouthpiece fabricated using a 3D printer as a fixation device for head and neck radiotherapy patients. METHODS: Five mouthpieces made of GC Exafine putty type (GCEP) were fabricated from five dry skull bones. After computed tomography reconstruction of the GCEP-made mouthpiece and its surface extraction, the MED610-made mouthpieces were replicated. The sizes of the GCEP and MED610 mouthpieces were measured with a vernier caliper in width, length, and height, respectively. The volumes of these mouthpieces were measured by Archimedes' principle using pure water. For dose evaluation, the GCEP and MED610 mouthpieces were placed in the same part of a water phantom, and a 4-MV X-ray beam was located at the left maxillary gingiva, buccal mucosa, and oral floor. The dose for the planning target volume (PTV) was evaluated. RESULTS: The differences in the mean size and volume between the GCEP and MED610 mouthpieces were 0.03 mm and 0.21 cm3, respectively. Compared with the conventional GCEP mouthpiece, the dose absorption in the MED610 mouthpiece was closer to that in only water. When the mouthpiece was within the PTV margin, the minimum coverage dose at 95% of the PTV increased by 2.4% in the maxillary gingiva and by 3.6% in the buccal mucosa. CONCLUSION: A 3D printer can construct a mouthpiece accurately. The MED610 mouthpiece is suitable for use in dosimetry in head and neck radiotherapy.

Role of primate cerebellar lobulus petrosus of paraflocculus in smooth pursuit eye movement control revealed by chemical lesion.

The primate lobulus petrosus (LP) of the cerebellar paraflocculus receives inputs from visual system-related pontine nuclei, and projects to eye movement-related cerebellar nuclei. To reveal a potential involvement of LP in oculomotor control, we lesioned LP unilaterally by local injections of ibotenic acid in three Macaca fuscata. We examined the effects of lesion on eye movements evoked by step (3 degrees )-ramp (5-15 degrees/s) moving target. To step-ramp moving target, the monkeys showed an initial slow eye movement and later a small catch-up saccade, which was followed by the post-saccadic pursuit nearly matching to the velocity of the ramp target motion. After LP lesioning, the velocity of post-saccadic pursuits in the ipsiversive and down-ward directions decreased by 20-40% in all three monkeys. These deficits lasted for at least 1 month, and some recovery was observed. In the amplitudes of catch-up saccades, no consistent changes were seen among the three monkeys after LP lesioning. These results suggest an involvement of LP in the primate smooth pursuit eye movement control.

Overall survival and post-progression survival are potent endpoint in phase III trials of second/third-line chemotherapy for advanced or recurrent epithelial ovarian cancer.

Purpose: A growing number of treatment options and active compounds in treatments have led to better outcomes for patients with advanced or recurrent epithelial ovarian cancer. We examined the association between progression-free survival (PFS), post-progression survival (PPS) and overall survival (OS) in phase III trials of second- and third-line chemotherapy for advanced or recurrent epithelial ovarian cancer. We aim to determine whether PFS or PPS is a surrogate of OS so that we can decide progress of disease is optimal endpoint for ovarian cancer. Methods: We identified 22 trials conducted between January 1, 2000 through December 31, 2014 by literature search. We divided OS into PFS and PPS, and assessed the association between OS and PFS/PPS. We also examined whether the year of trial enrollment completion was associated with any variables. Results: The median PPS was slightly longer in recent trials compared to older trials (10.0 vs. 8.8 months). While PPS was strongly associated with OS (r = 0.88) in all trials, PFS was moderately correlated with OS (r = 0.72). The correlation between OS and PPS in recent trials (r = 0.93) was stronger than in older trials (r = 0.84). Conclusions: Our findings indicate that PPS is highly associated with OS in second/third-line chemotherapy for advanced or recurrent epithelial ovarian cancer, while the association between PFS and OS is moderate. We recommend using OS as primary endpoint for clinical trial of ovarian cancer, however PFS is still an optional endpoint.

Nasal, oral, and pharyngolaryngeal manifestations of pemphigus vulgaris: Endoscopic ororhinolaryngologic examination.

Pemphigus vulgaris is an autoimmune blistering disorder that involves the skin and mucous membranes. Few reports have described nasal and oropharyngolaryngeal lesions in pemphigus vulgaris using an endoscopic ororhinolaryngologic examination. We retrospectively reviewed the clinical records of 11 patients with pemphigus vulgaris between 2001 and 2013 with respect to their symptoms, lesion sites, lesion features, and treatments received. All patients had undergone an endoscopic ororhinolaryngologic examination. Their mucosa-related symptoms were sore throat, oral pain, odynophagia, gingival bleeding, hoarseness, and epistaxis. The most frequent sites were the oral cavity (gingiva and buccal mucosa), larynx (epiglottis and vocal fold), oropharynx (soft palate), and nasal cavity (nasal septum). Lesions were typically characterized by erosion, erosion with a whitish exudate, and erythematous patches. Thus, our study findings reveal that pemphigus vulgaris involves both the nasal and oropharyngolaryngeal regions. Patients with pemphigus vulgaris should undergo an endoscopic ororhinolaryngologic examination to determine the range of their lesions.

Feasibility of patient dose reduction based on various noise suppression filters for cone-beam computed tomography in an image-guided patient positioning system.

We investigated the feasibility of patient dose reduction based on six noise suppression filters for cone-beam computed tomography (CBCT) in an image-guided patient positioning (IGPP) system. A midpoint dose was employed as a patient dose index. First, a reference dose (RD) and low-dose (LD)-CBCT images were acquired with a reference dose and various low doses. Second, an automated rigid registration was performed for three axis translations to estimate patient setup errors between a planning CT image and the LD-CBCT images processed by six noise suppression filters (averaging filter, median filter, Gaussian filter, edge-preserving smoothing filter, bilateral filter, and adaptive partial median filter (AMF)). Third, residual errors representing the patient positioning accuracy were calculated as Euclidean distances between the setup error vectors estimated using the LD-CBCT and RD-CBCT images. Finally, the residual errors as a function of the patient dose index were estimated for LD-CBCT images processed by six noise suppression filters, and then the patient dose indices for the filtered LD-CBCT images were obtained at the same residual error as the RD-CBCT image. This approach was applied to an anthropomorphic phantom and four cancer patients. The patient dose for the LD-CBCT images was reduced to 19% of that for the RD-CBCT image for the phantom by using AMF, while keeping a same residual error of 0.47 mm as the RD-CBCT image by applying the noise suppression filters to the LD-CBCT images. The average patient dose was reduced to 31.1% for prostate cancer patients, and it was reduced to 82.5% for a lung cancer patient by applying the AMF. These preliminary results suggested that the proposed approach based on noise suppression filters could decrease the patient dose in IGPP systems.

Features of oral, pharyngeal, and laryngeal lesions in bullous pemphigoid.

Bullous pemphigoid is an autoimmune bullous disease characterized by skin lesions, with or without oral lesions. The occurrence of pharyngolaryngeal lesions is very rare in affected patients. We conducted a study to investigate the characteristics of oral and pharyngolaryngeal lesions in bullous pemphigoid. Our study population was made up of 6 consecutively presenting outpatients-2 men and 4 women, aged 40 to 83 years (mean: 68.2)-who had been referred to our department over an 11-year period. Presenting symptoms included sore throat in all 6 patients and oral pain in 3. The sites of mucosal lesions included the soft palate, epiglottis, gingiva, hypopharynx, tongue, nasal cavity, and buccal mucosa. These lesions appeared as erosions, erosions with white coating, erythematous patches, and/or blisters. Mucosal lesions preceded skin lesions in 2 patients, appeared after skin lesions in 1 patient, and appeared simultaneously with skin lesions in 3 patients. We conclude that bullous pemphigoid sometimes involves the mucosa, such as that of the laryngopharynx and the oral cavity, and it can manifest as skin lesions. In the differential diagnosis of refractory pharyngolaryngeal lesions, bullous pemphigoid should be considered.

Physical imaging properties and low-contrast performance of a newly developed flat-panel digital radiographic system.

We investigated the clinical usefulness of a newly developed flat-panel detector (FPD) system by comparing its physical imaging properties and low-contrast detectability with those of a current FPD system. The newly developed CsI-based indirect FPD (Canon, CXDI-40C) and current Gd(2)O(2)S-based FPD (Canon CXDI-11) systems were used. Characteristic curves, resolution properties, radiographic noise, detective quantum efficiencies (DQEs) and low-contrast detectability for both systems were measured. The new FPD system showed considerably lower noise levels than those of the current FPD system. DQE (0) s of the new and current FPD systems were 75% and 35%, respectively. Observer performance tests of the contrast-detail (C-D) phantom indicated that the new FPD system can significantly improve low-contrast performance over that obtainable with the current FPD system under the same conditions of exposure. The new FPD system provided approximately 50% reduction in exposure while providing comparable detectability. The newly developed FPD system provides radiographic images with excellent inherent physical image quality and low-contrast performance.