Clinical practice guidelines for the diagnosis and management of acute sensorineural hearing loss.

OBJECTIVE: Acute sensorineural hearing loss represents a spectrum of conditions characterized by sudden onset hearing loss. The "Clinical Practice Guidelines for the Diagnosis and Management of Acute Sensorineural Hearing Loss" were issued as the first clinical practice guidelines in Japan outlining the standard diagnosis and treatment. The purpose of this article is to strengthen the guidelines by adding the scientific evidence including a systematic review of the latest publications, and to widely introduce the current treatment options based on the scientific evidence. METHODS: The clinical practice guidelines were completed by 1) retrospective data analysis (using nationwide survey data), 2) systematic literature review, and 3) selected clinical questions (CQs). Additional systematic review of each disease was performed to strengthen the scientific evidence of the diagnosis and treatment in the guidelines. RESULTS: Based on the nationwide survey results and the systematic literature review summary, the standard diagnosis flowchart and treatment options, including the CQs and recommendations, were determined. CONCLUSION: The guidelines present a summary of the standard approaches for the diagnosis and treatment of acute sensorineural hearing loss. We hope that these guidelines will be used in medical practice and that they will initiate further research.

Inflammation-Based Score (Combination of Platelet Count and Neutrophil-to-Lymphocyte Ratio) Predicts Pharyngocutaneous Fistula After Total Laryngectomy.

OBJECTIVES/HYPOTHESIS: Postoperative complications may depend on the systemic inflammatory response. We evaluated the predictive potential of the combination of platelet count and neutrophil-to-lymphocyte ratio (COP-NLR) for the incidence of pharyngocutaneous fistula (PCF) in patients who have undergone total laryngectomy. STUDY DESIGN: Retrospective cohort study. METHODS: Patients who underwent total laryngectomy between 2000 and 2020 were recruited from four hospitals. The correlations between the incidence of PCF and several risk factors, including the COP-NLR, were examined. Patients with both elevated platelet count and elevated neutrophil-to-lymphocyte ratio (NLR) were categorized as COP-NLR 2, and patients with either one or no abnormal values of both parameters were assigned as COP-NLR 1 and COP-NLR 0, respectively. RESULTS: A total of 235 patients were identified. The overall incidence of PCF was 12.3%. The cut-off value for NLR before surgery was set at 3.95 (sensitivity = 58.6%, specificity = 69.4%, area under the curve [AUC] = 0.635), and the platelet count was set at 320 × 109 /L (sensitivity = 27.6%, specificity = 87.9%, AUC = 0.571). Multivariate analysis revealed that COP-NLR was an independent risk factor for PCF (COP-NLR 1 vs. COP-NLR 0: odds ratio [OR], 4.17; 95% confidence interval [CI], 1.64 to 10.59; and COP-NLR 2 vs. COP-NLR 0: OR, 5.33; 95% CI, 1.38 to 20.56). CONCLUSIONS: COP-NLR is a novel predictive factor for the development of PCF in patients undergoing total laryngectomy. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1582-1587, 2022.

Objective evaluation of gustatory function after surgery for vestibular schwannoma: A pilot study.

OBJECTIVE: To evaluate the gustatory function before and after vestibular schwannoma (VS) surgery. METHODS: In this retrospective study, we evaluated the gustatory function of 12 patients who underwent VS surgery at Tsukuba University Hospital between 2012 and 2018. Gustatory function was examined using electrogustometry before VS surgery and 3 months, 6 months and 1 year after surgery. Electrogustometry was tested at the area mapped to the chorda tympani nerve, glossopharyngeal nerve and greater superficial petrosal nerve (GSPN). Intergroup mean comparisons of the threshold were performed using a one-way analysis of variance (ANOVA) followed by the Bonferroni post-hoc test. RESULTS: The gustatory function mapped to the chorda tympani nerve was significantly disturbed 6 months after the surgery as compared with the preoperative function (p = 0.033) and that the dysfunction recovered at 1 year. However, gustatory function mapped to the glossopharyngeal nerve and greater superficial petrosal nerve (GSPN) was not impaired. CONCLUSION: The gustatory function mapped to the chorda tympani nerve is impaired after surgery for VS. The dysfunction peaked at 6 months after surgery, and recovered within 1 year.

Efficacy of the pretreatment geriatric nutritional risk index for predicting severe adverse events in patients with head and neck cancer treated with chemoradiotherapy.

OBJECTIVE: The Geriatric Nutritional Risk Index (GNRI) is a simple and well-established nutritional assessment tool. Although concurrent chemoradiotherapy (CCRT), particularly cisplatin-based CCRT, is a standard treatment for locoregional advanced head and neck squamous cell carcinoma (HNSCC), the predictive factors of adverse events related to CCRT remain to be elucidated. The present study aimed to determine the association between GNRI and CCRT-related adverse events in patients of all ages with head and neck cancer (HNC) who underwent CCRT. METHODS: We retrospectively analyzed and compared the clinical characteristics and adverse events of 82 patients with HNC treated with CCRT according to their GNRI at the Department of Otolaryngology, Head and Neck Surgery, University of Tsukuba Hospital, between May 2014 and November 2019. The GNRI was calculated according to the equation: 1.489 × serum albumin (g/L) + 41.7 × (body weight/ideal body weight). We compared two groups: low GNRI (GNRI < 98) and normal GNRI (GNRI ≥ 98) groups. RESULTS: Eighty-two patients were enrolled in this study. There were 61 (76%) and 21 (26%) patients in the normal GNRI group and low GNRI group, respectively. There were significant differences in the incidence of grade ≥ 3 radiation mucositis, radiation dermatitis, and leukopenia between the low GNRI group and the normal GNRI groups. CONCLUSIONS: Patients with low GNRI scores were more likely to have severe adverse events. Pretreatment GNRI predicted severe CCRT-related adverse events in patients of all ages with HNC undergoing CCRT.

The Geriatric Nutritional Risk Index as a Prognostic Factor in Patients with Advanced Head and Neck Cancer.

OBJECTIVE: The Geriatric Nutritional Risk Index (GNRI) is a simple and well-established nutritional assessment tool and is a significant prognostic factor in various cancers. However, the role of the GNRI in predicting clinical outcomes in patients with advanced head and neck cancer (AHNC) has not been investigated. The aim of the present study was to examine the association between the GNRI and prognosis in patients with AHNC. STUDY DESIGN: Retrospective cohort study. METHODS: Data collected between 2002 and 2013 from Tsukuba University Hospital were reviewed. The GNRI was calculated according to the equation, 1.489 × serum albumin (g/l) + 41.7 × (body weight/ideal body weight). Characteristics and prognosis were compared among three risk groups: high (GNRI <82); intermediate (GNRI 82-98); and normal (GNRI >98). The primary endpoint was overall survival. RESULTS: A total of 248 AHNC patients were enrolled, among whom 134 (54%) exhibited no nutritional risk, 53 (21%) had an intermediate risk for malnutrition, and 61 (25%) exhibited a high risk for malnutrition. Three-year survival rates according to the three-group GNRI scores for normal, intermediate, and high risk were 76.6%, 56.3%, and 19.5%, respectively. As the three-group GNRI score increased, the risk for mortality significantly increased (adjusted hazard ratio [HR] for intermediate to normal, 1.73 [95% CI, 1.02-2.92]; adjusted HR for high to normal, 4.31 [95% CI, 2.71-6.84]). CONCLUSIONS: The GNRI could be considered a useful prognostic factor in patients with AHNC. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E151-E156, 2021.

Clinical practice guidelines for diagnosis and treatment of chronic tinnitus in Japan.

Clinical practice guidelines in Japan for tinnitus were published in May 2019. Effective treatment of tinnitus contributes to quality of life and may improve depression, anxiety, and cognitive function. The highest priority of treatment recommended by this guideline involves educational counseling, including an explanation of the mechanisms of tinnitus. Understanding tinnitus pathology has also been reported to be a therapeutically effective educational counseling strategy. Further, explaining how sound therapy such as tinnitus retraining therapy (TRT) works is effective. Psychological and cognitive behavioral therapies may be an option. Here, the hearing aid is coupled with a sound generator in order to administer sound therapy for patients with more-severe symptoms. In Japan, it can be difficult to perform psychotherapy alongside otorhinolaryngology, and exemplary sound therapy is more likely to be carried out. In any case, the purpose of treatment is not to eliminate tinnitus, but rather reduce distress that manifests in response to tinnitus by promoting sensory adaptation. Clinically, the most important subject is not the loudness of tinnitus, but the severity of tinnitus distress. TRT consists of educational counseling and sound therapy. The tinnitus handicap inventory (THI) is used to measure the distress level for tinnitus and to determine treatment priorities. Rehabilitation of tinnitus is important because anxiety and depression are often observed in patients with severe tinnitus. Additionally, drug administration should be avoided. As a surgical treatment, a cochlear implant can affect tinnitus symptoms. It is essential to establish a treatment policy according to the disease condition and degree of distress.

Associations between self-reported hearing loss and outdoor activity limitations, psychological distress and self-reported memory loss among older people: Analysis of the 2016 Comprehensive Survey of Living Conditions in Japan.

AIM: To investigate the associations between self-reported hearing loss and outdoor activity limitations, psychological distress and self-reported memory loss among older people. METHODS: We carried out a cross-sectional study using the data from the 2016 Comprehensive Survey of Living Conditions in Japan. The study population included people aged ≥65 years living at home, without a clinical diagnosis of dementia. The exposure of interest was self-reported hearing loss, whereas outcomes included outdoor activity limitations (Yes/No), psychological distress (Kessler Psychological Distress Scale score of ≥5) and self-reported memory loss (Yes/No). We carried out logistic regression analyses, adjusted for age, sex, smoking, alcohol, educational status, number of household members, household expenditure and number of clinical diagnoses requiring outpatient visits. RESULTS: Among 137 723 older people (mean age 74.5 years [standard deviation 7.4 years], 45.1% men), 12 389 (9.0%) reported hearing loss. People with hearing loss showed a higher prevalence of outdoor activity limitations (28.9% vs 9.5%, P < 0.001), psychological distress (39.7% vs 19.3%, P < 0.001) and memory loss (37.7% vs 5.2%, P < 0.001) than those without. The adjusted odds ratios comparing people with and without hearing loss were 2.0 (95% confidence interval 1.9-2.1), 2.1 (95% confidence interval 2.0-2.1) and 7.1 (95% confidence interval 6.8-7.4) for outdoor activity limitations, psychological distress and self-reported memory loss. CONCLUSIONS: This nationwide study suggested that older people with hearing loss were more likely to experience outdoor activity limitations, psychological distress and memory loss than those without. Early identification of and intervention in hearing loss might potentially reduce the risk of these poor health outcomes. Geriatr Gerontol Int 2019; 19: 747-754.

Modified combination of platelet count and neutrophil "to" lymphocyte ratio as a prognostic factor in patients with advanced head and neck cancer.

BACKGROUND: We evaluated the prognostic potential of the combination of platelet count and neutrophil to lymphocyte ratio (COP-NLR) in patients with advanced head and neck cancer. METHODS: We proposed a modified COP-NLR scoring system defined as follows: score 0 (platelet count level <300 × 109 /L and NLR <3); score 1 (platelet count level ≥300 × 109 /L and NLR <3); and score 2 (NLR ≥3). We assessed whether the modified scoring system had better performance as an indicator of prognosis than the existing COP-NLR scoring system (original and 4-group scores). RESULTS: A total of 248 patients were enrolled. The Akaike Information Criterion value with the modified COP-NLR score was the smallest among the 3 models. The 3-year survival rates according to the modified COP-NLR scores of 0, 1, and 2 were 80.6%, 59.9%, and 23.8%, respectively. CONCLUSION: The modified COP-NLR score is a useful prognostic marker in patients with advanced head and neck cancer.

Differences between acoustic trauma and other types of acute noise-induced hearing loss in terms of treatment and hearing prognosis.

OBJECTIVES: To evaluate the differences between acoustic trauma (AT) and other types of acute noise-induced hearing loss (ANIHL), we performed a literature search and case reviews. METHODS: The literature search based on online databases was completed in September 2016. Articles on ANIHL and steroid treatment for human subjects were reviewed. The source sounds and treatment sequelae of our accumulated cases were also reviewed. Hearing loss caused by gun-shots and explosions was categorized into the AT group, while hearing loss caused by concerts and other noises was categorized into the ANIHL group. RESULTS: Systemic steroid treatment did not appear to be effective, at least in the AT group, based on both the literature and our case reviews. However, effective recovery after treatment including steroids was observed in the ANIHL group. The difference in hearing recovery between the AT and ANIHL groups was statistically significant (p = .030), although differences in age, days from the onset to treatment and pretreatment hearing levels were not significant. CONCLUSIONS: Hearing recovery from AT is very poor, whereas, ANIHL is recoverable to some extent. Therefore, it is essential to differentiate between these two groups for accurate prediction of the hearing prognosis and evaluation of treatment effects.

Time Trends in Histological Features of Latent Prostate Cancer in Japan.

PURPOSE: The incidence of prostate cancer is reported to be increasing in Asia, including Japan. Although this trend has been attributed partly to a more Western diet, this assumption may involve variable confounders. Thus, we examined the histological features of contemporary vs historical latent prostate cancer. MATERIALS AND METHODS: Prostate specimens from a consecutive autopsy series (127, present study, 2008 to 2013) were examined. Each prostate gland was fixed and sliced in step sections. The findings were compared to those from another autopsy series (501 subjects, 1983 to 1987) at our institution. RESULTS: The mean age of subjects in the present study was 68.9 years while the mean age was not available from the earlier study. However, the mean age of the 566 entrants in the expanded database (1983 to 1989) was 63.5 years (p=0.0001). Prostate weight was significantly greater in the present study (p <0.0001). Latent prostate cancer was found more frequently in the present study than in the previous study (43.3% and 20.8%, respectively, p <0.0001). No distinct difference was seen in the proportion of tumor grade between the groups. An increasing trend of moderately to poorly differentiated tumors with advancing age was more evident in the present study. Index cancer volume was greater in the present study with 25.5% measuring 500 mm(3) or greater vs only 9.6% of cancers in the previous study (p=0.008). CONCLUSIONS: Chronological changes in the histological characteristics of Japanese latent prostate cancer were noted as it is more prevalent in the contemporary series. Our data may reflect a worldwide trend in increasingly aging societies.

Cooperation between Otolaryngologists and Occupational Health Support Centers.

Although prevention of noise-induced hearing loss is important, the risk of exposure to high-level sounds is not well recognized at workplaces. Occupational health support centers are expected to provide care resources for workers, wherein the workers can see an otolaryngologist to prevent noise-induced hearing loss. The Committee of Occupational and Environmental Health in the Oto-Rhino-Laryngological Society of Japan was planned to promote cooperation with occupational health support centers by means of registration of otolaryngologists as occupational health advisors. The committee conducted a survey using a questionnaire about the occupational health advisor registration process. Subsequently, there was an increase in the number of otolaryngologists who participated as occupational health advisors, with registrations occurring in 20 of the 47 occupational health support centers in Japan. Cooperation between otolaryngologists and occupational health support centers appears to be proceeding reasonably well and is the first step toward a more widespread effort for the prevention of noise-induced hearing loss at workplaces.

Outcome of T4 (International Union Against Cancer Staging System, 7th edition) or recurrent nasal cavity and paranasal sinus carcinoma treated with proton beam.

PURPOSE: To investigate the clinical features, prognostic factors, and toxicity of treatment for unresectable carcinomas of the nasal cavity and paranasal sinus (NCPS) treated with proton beam therapy (PBT). METHODS AND MATERIALS: Seventeen patients (13 men, 4 women) with unresectable carcinomas of the NCPS who underwent PBT at the University of Tsukuba between 2001 and 2007 were analyzed. The patients' median age was 62 years (range, 30-83 years). The tumors were located in the nasal cavity in 3 patients, the frontal sinus in 1, the ethmoid sinus in 9, and the maxillary sinus in 4. The clinical stage was Stage IVA in 5 cases, IVB in 10, and recurrent in 2. The tumors were deemed unresectable for medical reasons in 16 patients and because of refusal at a previous hospital 4 months earlier in 1 patient. All the patients received PBT irradiation dose of 22-82.5 GyE and a total of 72.4-89.6 GyE over 30-64 fractions (median 78 GyE over 36 fractions) with X-ray, with attention not exceeding the delivery of 50 GyE to the optic chiasm and brainstem. RESULTS: The overall survival rate was 47.1% at 2 years and 15.7% at 5 years, and the local control rate was 35.0% at 2 years and 17.5% at 5 years. Invasion of the frontal or sphenoid sinus was a prognostic factor for overall survival or local control. Late toxicity of more than Grade 3 was found in 2 patients (brain necrosis in 1 and ipsilateral blindness in 1); however, no mortal adverse effects were observed. CONCLUSION: Proton beam therapy enabled a reduced irradiation dose to the optic chiasm and brainstem, enabling the safe treatment of unresectable carcinomas in the NCPS. Superior or posterior extension of the tumor influenced patient outcome.

[A case of recurrent metastatic testicular cancer, successfully treated with paclitaxel, ifomide and cisplatin].

A 30-year-old man was diagnosed with testicular cancer, and underwent a radical orchiectomy. Pathological diagnosis was a mixed type nonseminomatous germ cell tumor. We diagnosed him as having stage I testicular cancer and decided to forgo adjuvant therapy. After 8 months of follow-up, he was admitted to our department because of brain, lung, and spleen metastases. Since the serum alpha-fetoprotein (AFP) level was present at a high level at 1,297 ng/ml, he was given combination chemotherapy consisting of 3 cycles of PEB, cisplatin, etoposide and bleomycin and one cycle of PE, cisplatin and etoposide. Because of the decline in lung diffusing capacity, the administration of bleomycin was stopped in the final course. However, the AFP level remained above 14 ng/ml. Then he was given one more cycle of VIP therapy (etoposide, ifosfamide, cisplatin), but the serum AFP level was increased to 56 ng/ml. Then, two cycles of chemotherapy with paclitaxel, ifosfamide and cisplatin were administered as salvage chemotherapy, which led to a normalization of the serum AFP level, and disappearance of the brain and spleen metastases. Residual lung mass was resected at the surgical department, and microscopically no viable tumor cells remained. Three years after his final hospitalization, the patient has had no evidence of recurrence or metastasis.

The importance of postoperative radiotherapy against polymorphous low-grade adenocarcinoma of the parotid gland: case report and review of the literature.

Polymorphous low-grade adenocarcinoma (PLGA) of the salivary gland is a disease entity that is a recently described form of adenocarcinoma. PLGA most commonly arises in the minor salivary glands. We report two cases of PLGA of the parotid gland. Case 1: A 52-year-old female visited the University of Tsukuba Hospital with a painless mass in the left parotid region. A superficial parotidectomy and postoperative radiotherapy were performed. The patient has been free from disease for 50 months. Case 2: A 55-year-old female initially noticed a painless slowly growing mass in the left parotid region. The tumor was removed with a superficial parotidectomy. The local recurrence was found 6 years after the initial surgery. The recurrent tumor was removed, and radiotherapy was administered thereafter. The patient has been free from the disease for 33 months since the last treatment. The treatment for the primary lesion is crucial for the prognosis since metastasis to the regional lymph node or to distant region is unusual in PLGA. Although surgical extirpation is the recommended modality for treatment of PLGA, wide resection with a safety margin is often difficult in the parotid gland because of the presence of the facial nerve. Our two cases were successfully treated with surgery and postoperative radiotherapy. Although our literature search revealed 32 previously reported cases of PLGA of the parotid gland, only five of the 32 cases were treated postoperative radiotherapy. We highlight the importance of postoperative radiotherapy for PLGA of the parotid gland.

Basaloid squamous cell carcinoma of the maxillary sinus: a report of two cases.

Basaloid squamous cell carcinoma (BSCC) is a highly aggressive neoplasm and a histologically distinctive variant of squamous cell carcinoma. Since the first description by Wain et al. in 1986, only 18 cases with BSCC in the nasal cavity or in the paranasal cavity have been reported in the English literature. We report herein two cases of BSCC of the maxillary sinus. Case 1 was 78-year-old man, who received preoperative radiotherapy and operation. He was alive without disease for 25 months after the operation. Case 2 was a 60-year-old man who received radiotherapy without operation. He died of lung metastasis 6 months after the initial diagnosis. We reviewed the clinical features of BSCC from the literature.

Successful treatment of eosinophilic otitis media using ramatroban: report of two cases.

OBJECTIVE: The pathogenesis of eosinophilic otitis media is not yet fully understood. The purpose of this paper is to describe the clinical course of our two patients with eosinophilic otitis media and to discuss the pathogenesis and treatment of this intractable condition. METHODS: Two cases of eosinophilic otitis media were treated with ramatroban. RESULTS: The middle ear effusion has been well controlled in both patients for more than 1 year with minimal corticosteroid therapy. CONCLUSIONS: Our experience suggests that the pathogenesis of eosinophilic otitis media is related to the pharmaceutical effects of ramatroban, i.e., inhibition of the thromboxane A2 receptor (TP) and the chemoattractant receptor-homologous molecule expressed on Th2 cells (CRTH2).

Preoperative evaluation of ossicular chain abnormality in patients with conductive deafness without perforation of the tympanic membrane.

OBJECTIVE: To evaluate the usefulness of pure-tone audiometry, tympanometry, and liquid and acoustic reflex (AR) tests in the differential diagnosis of ossicular fixation and discontinuity. DESIGN: A prospective clinical trial. SETTING: Tertiary referral center. PATIENTS: Thirty-nine patients (46 ears) undergoing operations at University of Tsukuba Hospital, Tsukuba, Japan, from 1990 through 2003 for conductive deafness without perforation of the tympanic membrane. Clinical examinations for the preoperative diagnosis included pure-tone audiometry, tympanometry, and liquid and AR tests. We compared the preoperative diagnosis with the surgical findings. RESULTS: Although neither pure-tone audiometry nor tympanometry contributed to the differential diagnosis of ossicular chain abnormality, liquid and AR test results showed a significant difference between fixation and discontinuity of the ossicular chain. With the liquid test, bone conduction at lower frequencies was improved by filling the external auditory canal with water at lower frequencies in cases of ossicular fixation. In contrast to the findings observed in ossicular fixation, no improvement of the threshold of bone conduction was recognized at any frequency in the ears with ossicular discontinuity. In ipsilaterally stimulated AR, the reversed pattern was the most marked at 2000 and 500 Hz in ossicular fixation and discontinuity, respectively. CONCLUSION: Liquid and AR tests are reliable examinations for the differential diagnosis of ossicular fixation and discontinuity.

[Complete neurological recovery in a patient with decerebrate rigidity following cardiac arrest from acute airway obstruction by advanced laryngeal cancer].

A 59-year-old man presented with severe dyspnea caused by advanced laryngeal cancer. As he had disregarded the dyspnea for a month, we did not have enough information about the extent of the tumor. The pulse oximeter showed 88% with oxygen inhalation. Because of severe dyspnea, he could not maintain supine position. Fiberoptic laryngoscopy showed tumor bulk obstructing airway directly. In the operating room, at first, a cricothyroid membrane puncture was attempted under local anesthesia but the procedure was abandoned when the patient became hypoxic and unconscious. Immediately tracheostomy and cardiopulmonary resuscitation were performed. Tumor bulk had displaced the trachea and surrounding structures, making a tracheostomy difficult. Nine min after loss of consciousness, a secure airway was obtained. However, he was still unconscious and developed characteristic decerebrate rigidity. Therefore the patient was treated with infusion of thiamylal and free radical scavenger and mild hypothermia therapy (bladder temperature 34 degrees C). On the fifth day of this treatment, after rewarming and discontinuation of thiamylal, the patient responded to command. He recovered with no neurological deficits. This case suggests that combined treatment with barbiturate, free radical scavenger, and mild hypothermia therapy is effective to minimize ischemic brain damage after cardiopulmonary resuscitation.