Simple underlay myringoplasty.

OBJECTIVE: To introduce simple underlay myringoplasty which is widely performed in Japan. PATIENTS: 391 ears with perforated eardrum underwent simple underlay myringoplasty from 2000 to 2004, and which were followed up for more than six months after surgery. METHODS: After removing the margin of the perforation by a transcanal approach under local anaesthesia, a connective tissue graft was inserted through the perforation and lifted to contact the edge. Fibrin glue was dropped on the contact area. There was no packing in the canal or in the middle-ear cavity. If the perforation remained, re-closure was attempted using the patient's frozen tissue. RESULTS: The rate of closure after the initial attempt was 304/391 (77.7 per cent), and that after re-closure for unsuccessful cases was 70/87 (80.5 per cent). The overall rate was 374/391 (95.7 per cent). There were no serious complications such as sensorineural hearing loss. CONCLUSIONS: Simple underlay myringoplasty is a simple and minimally invasive procedure employing fibrin glue and has led to a high closure rate of the eardrum.

Mutation at codon 130 in hepatitis B virus (HBV) core region increases markedly during acute exacerbation of hepatitis in chronic HBV carriers.

Mutations within T-cell or B-cell epitopes are suggested to have some influence on the clinical course of chronic hepatitis B virus (HBV) infection. To investigate the relationship between liver cell injury and heterogeneity of the HBV core gene, we focused on the sequence of codon 130, which is located on both T- and B-cell epitopes, and serially analyzed the proportion of mutant virus (core130Thr) to wild-type virus (core130Pro) during the exacerbation of chronic hepatitis B. Sera obtained serially from five HBV carriers who had exacerbation of hepatitis, and three asymptomatic HBV carriers (ASCs) with persistently normal serum aminotransferase (ALT) values were studied, using the restriction fragment length polymorphism (RFLP) method. Core130Pro predominated in the sera in the remission state, but core130Thr increased markedly in parallel with ALT elevation and decreased again after the ALT peak, followed by the predominance of core130Pro, in all the five patients. In one patient, the ratio of core130Thr/core130Pro (Thr/Pro) was more than 70% at the ALT peak. On the other hand, in sera from the three ASCs core130Pro always predominated, and no divergence was identified in the ratio of Thr/Pro. Our data suggest that codon 130 is one of the most important immunogenic regions in the HBV core gene and that elevation of Thr/Pro could be the result of immune selection.

Properties of hepatitis B virus genome recovered from Vietnamese patients with fulminant hepatitis in comparison with those of acute hepatitis.

Among the many mutations found in the hepatitis B virus (HBV) genome, some have been associated with fulminant hepatitis, as exemplified by precore-defective mutations. The aim of this study was to determine whether such mutations also are found in Vietnamese cases of fulminant hepatitis B. The full-genome nucleotide sequence of HBV in three patients with fulminant hepatitis (F-2, F-3, and F-6) and one with acute hepatitis (A-3), who were admitted to Cho Ray Hospital, Ho Chi Minh City, Vietnam was ascertained. Additionally, two patients with fulminant hepatitis (F-1 and F-7) and three with acute hepatitis (A-1, A-2, and A-5) were examined only for the precore/core region of HBV. Remarkably, the nonsense mutation at precore codon 28 (Trp82Stop) was found in four of the five patients with fulminant hepatitis, while all the acute hepatitis patients harbored wild type (one had a mixture of wild and mutant types). The missense mutations within the core region, Ile97Leu and Pro130Ile/Thr/Ser, were also remarkable in fulminant hepatitis. Only F-2 was free from these precore/core mutations, but F-2 was unique in that it possessed a chimeric genotype: it could be classified into genotype C as a whole, but its X region was of genotype B, like the other four fulminant hepatitis isolates (F-1, F-3, F-6, and F-7). The codon 41 of the X protein was Pro in all three fulminant hepatitis cases examined for this region, while it was Ser in the wild-type isolates of genotype B. Of note as negative data, the mutations C1653T and T1753M of the enhancer II (Enh II) and A1762T and G1764A of the precore/core promoter regions, once reported to be relevant to severe or fulminant hepatitis, were not found in the present cases. The results with the Vietnamese cases of fulminant hepatitis corroborated results of previous studies with respect to the mutations Trp28Stop of precore and Ile97Leu and Pro130Ile/Thr/Ser of core, but not for the mutations within Enh II and precore/core promoter region. Whether the Ser41Pro mutation in the X region of genotype B HBV is Vietnam-specific or disease-specific deserves further investigation.

[Neuroimaging findings of hemiconvulsions, hemiplegia, epilepsy (HHE) syndrome].

A 32-year-old man with hemiconvulsions, hemiplegia, epilepsy (HHE) syndrome is described. He was well developed with a normal pregnancy and delivery, but at age 10 months, he had status epilepticus during a febrile illness. Thereafter, he was noted to have left hemiparesis and mental retardation with recurrent hemiconvulsions. Magnetic resonance (MR) images showed atrophy and degeneration of the right cerebral cortex and white matter, homolateral thalamus, caudate nucleus, and hippocampus, with hyperintensities in both T2-weighted (TR/2200, TE/90) and proton (TR/2200, TE/30) images. There were also slight bilateral cerebellar atrophies. Quantitative single photon emission computed tomographic (SPECT) images using technetium-99m-ethyl cysteinate dimer (99mTc-ECD) revealed markedly reduced cerebral blood flow (CBF) in the right cerebral hemisphere, homolateral thalamus, caudate nucleus and bilateral cerebellum. Bilateral putamen and the medial occipital lobe showed normal findings on MR images and normal regional CBF in SPECT images. We suppose these selective neuronal injures in this case of HHE syndrome will be mainly due to histotoxic factors in epileptic brain damage.

Sound localization for a virtual sound source in cases of chronic otitis media.

Sound localization in subjects with chronic otitis media (COM) was examined before and soon after ear surgery by means of virtual sound presented by headphones, sound being synthesized based on the head-related transfer functions (HRTFs) in a normal subject. The localization ability in COM patients was usually worse than that in normal subjects, but was better than expected when compared with cases of acute loss. On the other hand, the effects of hearing improvement on localization ability observed in COM patients were smaller than those of simulated acute hearing loss achieved by earplugs in normal subjects. This seems to suggest that the localization cues in patients with chronic hearing loss are different from those under normal conditions.

Interferon-alpha-induced thyroid dysfunction in patients with chronic active hepatitis C: a transient, reversible and self-limited dysfunction.

To survey the prognoses of interferon-alpha (IFNalpha)-induced thyroid dysfunction, a total of 100 patients (49 males and 51 females) with biopsy-proven chronic active hepatitis C were studied. Either during or after IFNalpha therapy, 29 patients (33.7%) revealed suppression/elevation of thyroid stimulating hormone (TSH) or both, transient thyrotoxicosis (TSH less than 0.1 microU/ml) or transient hypothyroidism (TSH 5.0-190.95 microU/ml). However, the thyroid function normalized without supplementation of the thyroid hormone in the follow-up period. In the same period, one of the 14 control patients (7.1%) developed thyroid dysfunction. Thyroid abnormalities developed significantly more in patients with IFNalpha therapy than in those without IFNalpha therapy. The findings suggest that the occult autoimmune disorder becomes overt with IFNalpha treatment in patients with pre-existent autoimmune thyroid disease. IFNalpha-induced thyroid dysfunction is transient, reversible and self-limited. It is not necessary to discontinue IFNalpha therapy when thyroid dysfunction develops.

Serum androgen levels in hyperthyroid women.

Thyroid hormone is known to affect androgen metabolism, however, there are few studies in which alterations of androgen metabolism are simultaneously examined in patients with clinical thyroid disorders. In this study, we investigated the alterations of thyroid hormone and androgens before and during treatment in patients with hyperthyroidism. Fifteen female patients with hyperthyroidism due to Graves' disease were studied. From these patients, blood samples were obtained before treatment and at 1 month (M), 2M, 3M, 4M and 6M after beginning of treatment. Concentrations of free T4(FT4), free T3(FT3), testosterone (T), androstenedione (delta 4A), dihydrotestosterone (DHT), 5 alpha-androstane-3 alpha, 17 beta-diol(3 alpha-diol) and androsterone (AD) and sex hormone binding globulin (SHBG) were measured by radioimmunoassays (RIAs) or immunoradiometric assay (IRMA). As normal controls, ten healthy women were also studied. Before treatment concentrations of DHT (mean +/- SD: 3.35 +/- 0.78 nmol/L), 3 alpha-diol (0.78 +/- 0.11 nmol/L), AD (6.73 +/- 0.64 nmol/L) and SHBG (184.9 +/- 68.1 nmol/L) were significantly elevated compared with those of normal controls. T and delta 4A levels were not significantly different from normal values. DHT/T ratio indicating 5 alpha-reductase activity was 4.62 +/- 2.55 and significantly higher than that in normal controls. At 2 months after beginning of treatment with anti-thyroid drugs, thyroid function (FT4 and FT3) became normal and at 3 months after beginning of treatment, DHT, 3 alpha-diol, AD and DHT/T ratio decreased to normal range. SHBG level was gradually decreased, however still higher than that of the normal control group at 6 months after beginning of treatment. There was a time lag in recovery between serum androgen levels and SHBG level.

[Congenital cholesteatomas in Japanese--forty from our experience and fifty-five from a survey of the Japanese literature].

To determine the locations of congenital cholesteatomas and to elucidate the relationship between ossicular anomalies and congenital cholesteatomas, cholesteatomas from our patients and those reported in the Japanese literature were investigated. We analyzed 40 ears with congenital cholesteatomas (38 patients) experienced by us during the past 9 years. Our criteria of congenital cholesteatoma were as follows: 1. The tympanic membrane manifests neither retraction, perforation, nor granulation, 2. There is no continuity between the tympanic membrane and the matrix of a cholesteatoma. Twenty patients with past histories of otitis media were included. Thirty-three patients (87%) were males and 2 had bilateral congenital cholesteatomas. The ages of the patients ranged from 2 to 46 years (mean: 10.7). A survey of the Japanese literature revealed 55 additional cases of congenital cholesteatoma reported by others.

Hemorrhage and abnormal veins in acoustic neurinoma: MR findings.

We reviewed the MR imaging findings of 57 acoustic neurinomas which were verified at surgery or diagnosed on the basis of neuroradiological and neurootological data. Two uncommon MR findings of acoustic neurinoma were found. First, hypointense areas were observed on T2-weighted images in five of the 12 tumors larger than 25 mm in diameter. These hypointense areas represented hemosiderin deposition secondary to occult intratumoral hemorrhage. Second, curvilinear or round signal voids were noted at the periphery of 11 large or medium-sized tumors, and these corresponded to "abnormal veins" seen on angiographic studies.

[A case of a right bronchial foreign body (rice cake)].

We had a case of a bronchial foreign body (rice cake). A 73-year-old male with severe dyspnea was taken by emergency car. His right breathing sound was very weak, but chest X-ray showed no changes. We diagnosed it as right bronchial foreign body and we could endoscopically remove the foreign body with basket-forcep successfully. We could save his life.

Reinforcing aerosol cisplatin for radiotherapy of laryngeal cancer.

To attain its increased tumor concentration and to avert its systemic adverse effects, aerosol cisplatin (CDDP) was incorporated into radiotherapy (RT) of laryngeal cancer. Nine patients were asked to inhale the aerosol following each RT session. Their clinical tumor response was favorable, and histopathologic survey in selected cases revealed elimination of viable cancer cells. However limited, there have been no reports of cancer recurrence yet. This reinforcing plan of aerosol CDDP for RT bleomycin would certainly offer a better way of treating laryngeal cancer, and probably those malignancies facing the nasopharyngobronchial airway as well.

Bone destruction mechanisms in chronic otitis media with cholesteatoma: specific production by cholesteatoma tissue in culture of bone-resorbing activity attributable to interleukin-1 alpha.

To clarify specific mechanisms underlying cholesteatoma-induced bone destruction, surgical specimens of middle ear inflammatory granulation tissue with or without cholesteatoma were maintained in vitro and the bone-resorbing activity in their culture supernatants was analyzed by means of calcium release from mouse calvaria. Almost the same levels of bone-resorbing activity and prostaglandin (PG) E2 were found in the supernatants of both types of tissue. By contrast, aural polyp tissue yielded hardly any such activity or PGE2. Under the influence of indomethacin, however, only tissue with cholesteatoma produced considerable bone resorption activity, whereas PGE2 production was suppressed completely. Such activity in the cholesteatoma culture supernatant was not due to contamination of endotoxin and proved to be blocked by the introduction of anti-interleukin (IL)-1 alpha antibody into the calvarial assay system. Anti-IL-1 beta antibody had no effect on such activity. Interleukin-1 alpha was detected only in cholesteatoma tissue culture supernatants by means of enzyme-linked immunosorbent assay and by bioassay. These data suggest that the bone destruction in otitis media with cholesteatoma may be attributed to IL-1 alpha in addition to PGE2.

Labyrinthine fistulae caused by cholesteatoma. Improved bone conduction by treatment.

In five cases of labyrinthine fistulae caused by extensive cholesteatoma, more than 30-dB improvement in bone conduction was observed in four postoperative cases and in one case after preoperative administration of antibiotics. In each case, a fistula of more than 2 mm in length was present at the lateral semicircular canal, and membranous labyrinthine wall was exposed when the cholesteatoma membrane was removed. These five cases were considered to be in the stage of serous labyrinthitis. The experience with these cases shows that emergent antibiotic treatment and surgery are appropriate for cases with reduced bone conduction in which labyrinthine fistula caused by cholesteatoma is suspected. In addition, as the reduction of bone conduction does not necessarily preclude the possibility of good postoperative hearing, tympanoplasty may be appropriate even for cases with markedly reduced bone conduction due to labyrinthine fistulae.

A case of carcinoid tumor of the middle ear producing peptide hormones.

We report 6th case of carcinoid tumor of the middle ear in a 16-year-old man. The clinical, histologic, immunohistochemical and ultrastructural features are discussed. The tumor in the attic and the tympanic cavity was successfully excised by radical mastoidectomy. Microscopically, the argyrophilic property and neurosecretory granules which are characteristic of carcinoid tumor were found in the cytoplasm of tumor cells. Furthermore, peptide hormones were confirmed immunohistochemically in this case. This tumor should be considered in the differential diagnosis when biologically lowgrade tumor with glandular and trabecular architectures are encountered in the middle ear.

[Radiochemotherapy of head and neck cancers: dose reduction through the combination of cisplatin, bleomycin and tegafur].

Twenty-four cases of squamous cell carcinomas of the larynx and maxillary sinus were irradiated with or without cisplatin during a period from April 1973 through March 1984. Both bleomycin in oil and tegafur were administered irrespective of cisplatin. Therapeutic effectiveness was critically evaluated by means of serial biopsy and/or surgery. Radiotherapy alone could not bring about negative conversion of the biopsies, but ultimate negative conversion was observed in 18 out of the 24 cases when chemotherapeutics were appropriately combined. The five positives underwent surgery. In the cases of maxillary cancer, mixed infections appeared to interfere with the curative effectiveness of the radiochemotherapy. A resulting dosage reduction of 15Gy was observed in radiotherapy for negative conversion and one of 10mg for bleomycin as a result of incorporation of cisplatin.

Organic acids and anaerobic microorganisms in the contents of the cholesteatoma sac.

Organic acids in the contents of the cholesteatoma sac from 28 cases were studied by gas chromatographic technique. Five volatile fatty acids (acetate, propionate, isobutyrate, butyrate and isovalerate) and lactate were detected in large amounts, which may lower the pH of the cholesteatoma content. These acids were considered to be derived from products of anaerobic microorganisms. Therefore, the contents from 12 cases were cultured anaerobically in a glove box. Obligate microorganisms were identified in 92% of the cases and Peptococcus, Bacteroides, and Clostridium species were frequently isolated. In vitro, such obligate anaerobes produced various organic acids from the cholesteatoma content. Facultatives such as Staphylococcus aureus and Proteus mirabilis produced acetate in the content under aerobic and anaerobic conditions, whereas no organic acid was produced by Pseudomonas aeruginosa. Organic acids in the cholesteatoma content could be fermentative products made by the microorganisms, anaerobes and facultatives, which use the content as a substrate for acid production.

Bone destruction due to the rupture of a cholesteatoma sac: a pathogenesis of bone destruction in aural-cholesteatoma.

Severe bone destruction in a cholesteatoma is one of the characteristic clinical features. To clarify the mechanism of bone destruction in cholesteatoma, the matrix of cholesteatoma and the attached bone, obtained during middle ear surgery, was observed by light microscope. Rupture of the epithelial lining in a cholesteatoma and the escaping contents (keratin), which gave rise to intense characteristic granulations in subepithelial tissue, were found. Furthermore bone destruction was always found at the site of subepithelial tissue of cholesteatoma. From these facts, the escape of contents from the sac of cholesteatoma into the subepithelial layer is considered to be an important factor in the mechanism of bone destruction.