Long-term result of meatoplasty using inferiorly based retroauricular island pedicle flap for external auditory canal stenosis.

OBJECTIVE: To characterize the long-term outcomes of meatoplasty using our new technique, inferiorly based retroauricular island pedicle flap for external auditory canal (EAC) stenosis. METHODS: A long-term clinical analysis of meatoplasty for nine patients (mean age, 33 years; age range, 8-64 years) with stenotic EAC was performed. The follow-up period after meatoplasty ranged from 5 years to 14 years, with a mean duration of 8.4 years. We compared preoperative and postoperative otoscopic findings, high-resolution computed tomographic (CT) images of the EAC, and hearing levels. RESULTS: Otoscopic examinations demonstrated widened EAC in eight of the nine patients. There was a significant increase in the size of the EAC on postoperative CT examinations when compared with the preoperative state. The hearing outcome in all patients was variable. The postoperative air-bone gap (ABG) was closed to 10dB or less in two cases, while the other seven cases showed ABG ranging from 15.0dB to 57.5dB. CONCLUSIONS: We performed meatoplasty using inferiorly based retroauricular island pedicle flap for nine patients with EAC stenosis and eight of the nine patients demonstrated satisfactory patent EAC during a mean follow-up of 8.4 years.

[A case report: primary nasal tuberculosis].

A 62-year-old female visited us complaining of lacrimination and the swelling of the left side of the nasal dorsum. Granulation tissues were seen on the anterior-lateral wall of the left nasal cavity, and an imaging study revealed a mass occupying both the left nasal cavity and the anterior ethmoid sinuses invading the face with erosion of the nasal bone. Histological examination showed an epithelioid granuloma without caseous necrosis which mostly suggested sarcoidosis. The affected lesions became larger 11 months after the initial examination, and a biopsy was performed again, which revealed the same pathological findings. Although the biopsy specimen was negative based on the PCR findings, tubercle bacillus was detected in the culture 7 weeks later. The patient was finally diagnosed as having primary tuberculosis of the nose and paranasal sinuses because systemic examination showed no evidence of tuberculosis in other areas. She was treated with antituberculosis medication, and the affected nasal lesions disappeared. It is important to perform a biopsy and tissue culture repeatedly when we encounter an intractable and undiagnosed disease in the nasal cavity.

RNA analysis of inner ear cells from formalin fixed paraffin embedded (FFPE) archival human temporal bone section using laser microdissection--a technical report.

OBJECTIVE: Molecular analysis using archival human inner ear specimens is challenging because of the anatomical complexity, long-term fixation, and decalcification. However, this method may provide great benefit for elucidation of otological diseases. Here, we extracted mRNA for RT-PCR from tissues dissected from archival FFPE human inner ears by laser microdissection. METHODS: Three human temporal bones obtained at autopsy were fixed in formalin, decalcified by EDTA, and embedded in paraffin. The samples were isolated into spiral ligaments, outer hair cells, spiral ganglion cells, and stria vascularis by laser microdissection. RNA was extracted and heat-treated in 10 mM citrate buffer to remove the formalin-derived modification. To identify the sites where COCH and SLC26A5 mRNA were expressed, semi-nested RT-PCR was performed. We also examined how long COCH mRNA could be amplified by semi-nested RT-PCR in archival temporal bone. RESULTS: COCH was expressed in the spiral ligament and stria vascularis. However, SLC26A5 was expressed only in outer hair cells. The maximum base length of COCH mRNA amplified by RT-PCR was 98 bp in 1 case and 123 bp in 2 cases. CONCLUSION: We detected COCH and SLC26A5 mRNA in specific structures and cells of the inner ear from archival human temporal bone. Our innovative method using laser microdissection and semi-nested RT-PCR should advance future RNA study of human inner ear diseases.

[Tonsillectomy in recurrent IgA nephropathy after renal transplantation].

Many reports suggest tonsillectomy efficacy in subjects with early-stage IgA nephropathy (IgAN). Post-renal-transplant treatment in recurrent IgAN must, however, be assessed carefully. Recent reports show that tonsillectomy to also be effective in such recurrent cases. We studied 13 subjects with recurrence diagnosed histopathologically in allogenic kidney transplantation involving tonsillectomy from March 2008 to March 2010. Tonsillectomy was done on average of 74 months (15-180 months) after transplantation. Subjects averaged 44.8 years of age (29-67 years old). Buried tonsil was most common and 12 of 13 involved pus. One subject suffered slight bleeding 1 week after tonsillectomy, manageable conservatively. Steroid pulse therapy was added in 1 case after tonsillectomy due to histopathological renal biopsy suggesting severe renal injury. In most cases, serum creatinine (SCr) and urinary findings improved after tonsillectomy, which is thus expected to be effective in subjects with recurrent early-stage IgAN following renal transplantation, not only in those with IgAN.

In vitro metabolism of rivoglitazone, a novel peroxisome proliferator-activated receptor γ agonist, in rat, monkey, and human liver microsomes and freshly isolated hepatocytes.

The in vitro metabolism of rivoglitazone, (RS)-5-{4-[(6-methoxy-1-methyl-1H-benzimidazol-2-yl)methoxy]benzyl}-1,3-thiazolidine-2,4-dione monohydrochloride, a novel thiazolidinedione (TZD) peroxisome proliferator-activated receptor γ selective agonist, was studied in liver microsomes and freshly isolated hepatocytes of rat, monkey, and human as well as cDNA-expressed human cytochrome P450 (P450) and UDP-glucuronosyltransferase (UGT) enzymes. Fourteen metabolites were detected, and these structures were elucidated by liquid chromatography-tandem mass spectrometry. Five initial metabolic pathways of rivoglitazone consisting of four oxidation pathways and one N-glucuronidation pathway were predicted in correspondence with those proposed for in vivo studies using rats and monkeys. In metabolization using liver microsomes, the TZD ring-opened mercapto amide (M22) and TZD ring-opened mercapto carboxylic acid (M23) were identified as the primary metabolite of the TZD ring-opening pathway and its sequential metabolite, which have not been detected previously from in vivo studies. Combination with S-adenosyl-L-methionine was useful to obtain the sequential S-methylated metabolites from the oxidative metabolites. N-Glucuronide and sequential TZD ring-opened metabolites were also found in liver microsomes in the presence of UDP-glucuronic acid. The O-demethyl-O-sulfate (M11), which is the major in vivo metabolite in rats and monkeys, was detected in all species of hepatocytes. In addition, a TZD ring-opened S-cysteine conjugate (M15) was detected in human hepatocytes. From these results, the in vivo metabolic pathways in humans were predicted to be the four oxidation and one N-glucuronidation pathways. The four oxidative metabolites were formed by multiple human P450 enzymes, and N-glucuronide was formed by UGT1A3 and UGT2B7.

Pharmacokinetics, metabolism, and disposition of rivoglitazone, a novel peroxisome proliferator-activated receptor γ agonist, in rats and monkeys.

The pharmacokinetics, metabolism, and excretion of rivoglitazone [(RS)-5-{4-[(6-methoxy-1-methyl-1H-benzimidazol-2-yl)methoxy]benzyl}-1,3-thiazolidine-2,4-dione monohydrochloride], a novel thiazolidinedione (TZD) peroxisome proliferator-activated receptor γ selective agonist, were evaluated in male F344/DuCrlCrlj rats and cynomolgus monkeys. The total body clearance and volume of distribution of rivoglitazone were low in both animals (0.329-0.333 ml per min/kg and 0.125-0.131 l/kg for rats and 0.310-0.371 ml per min/kg and 0.138-0.166 l/kg for monkeys), and the plasma half-life was 4.55 to 4.84 h for rats and 6.21 to 6.79 h for monkeys. The oral bioavailability was high (>95% in rats and >76.1% in monkeys), and the exposure increased dose proportionally. After administration of [(14)C]rivoglitazone, radioactivity was mainly excreted in feces in rats, whereas radioactivity was excreted in urine and feces with the same ratio in monkeys. Because excreted rivoglitazone in urine and bile was low, metabolism was predicted to be the main contributor to total body clearance. The structures of 20 metabolites (M1-M20) were identified, and 5 initial metabolic pathways were proposed: O-demethylation, TZD ring opening, N-glucuronidation, N-demethylation, and TZD ring hydroxylation. O-Demethylation was the main metabolic pathway in both animals, but N-demethylation and TZD ring hydroxylation were observed only in monkeys. N-Glucuronide (M13) was nonenzymatically hydrolyzed to TZD ring-opened N-glucuronide (M9), and the amount of these metabolites in monkeys was larger than that in rats. In plasma, rivolitazone was observed as the main component in both animals, and O-demethyl-O-sulfate (M11) was observed as the major metabolite in rats but as many minor metabolites in monkeys.

Identification of novel metabolic pathways of pioglitazone in hepatocytes: N-glucuronidation of thiazolidinedione ring and sequential ring-opening pathway.

The metabolism of [(14)C]pioglitazone was studied in vitro in incubations with freshly isolated human, rat, and monkey hepatocytes. Radioactivity detection high-performance liquid chromatography analysis of incubation extracts showed the detection of 13 metabolites (M1-M13) formed in incubations with human hepatocytes. An identical set of metabolites (M1-M13) was also detected in monkey hepatocytes. However, in rat hepatocytes, M1 through M3, M5 through M7, M9 through M11, and M13 were also detected, but M4, M8, and M12 were not detected. The structures of the metabolites were elucidated by liquid chromatography/tandem mass spectrometry using electrospray ionization. Novel metabolites of pioglitazone detected using these methods included thiazolidinedione ring-opened methyl sulfoxide amide (M1), thiazolidinedione ring-opened N-glucuronide (M2), thiazolidinedione ring-opened methyl sulfone amide (M3), thiazolidinedione ring N-glucuronide (M7), thiazolidinedione ring-opened methylmercapto amide (M8), and thiazolidinedione ring-opened methylmercapto carboxylic acid (M11). In summary, based on the results from these studies, two novel metabolic pathways for pioglitazone in hepatocytes are proposed to be as follows: 1) N-glucuronidation of the thiazolidinedione ring of pioglitazone to form M7 followed by hydrolysis to M2, and methylation of the mercapto group of the thiazolidinedione ring-opened mercapto carboxylic acid to form M11; and 2) methylation of the mercapto group of the thiazolidinedione ring-opened mercapto amide to form M8, oxidation of M8 to form M1, and oxidation of M1 to form M3.

Quantitative cellular level analysis of mitochondrial DNA 3243A > G mutations in individual tissues from the archival temporal bones of a MELAS patient.

CONCLUSION: We could represent the first quantitative analysis of the mutation rate at the cellular level in human inner ear of a patient with MELAS (mitochondrial encephalopathy, lactic acidosis and stroke-like episodes) by combining laser capture microdissection (LCM) and quantitative real time PCR. OBJECTIVES: We previously reported combining LCM and PCR to isolate mtDNA from the cells of specific tissues within a human archival celloidin-embedded temporal bone section without known otological history. Using this method, we quantitatively analyzed the rate of mtDNA 3243A > G mutation in the inner ear of a MELAS patient, and examined the correlation of the mutation rate at the cellular level and their histopathological condition. METHODS: We extracted each inner ear organs using LCM from temporal bone sections of a MELAS patient, and studied the mutation rate, which was calculated as the ratio of the amount of mutant mtDNA to the total mtDNA. RESULTS: We found that the mtDNA mutation rate was high in spiral ganglion cells and the saccular macula, but was comparatively low in hair cells of the organ of Corti, the stria vascularis and the facial nerve. With the exception of the stria vascularis, there was a good correlation between the mutation rate and the histological findings.

Nasal downward swing approach coupled with the facial dismasking flap.

OBJECTIVE: For the purpose of an en bloc resection with sufficient margins, a wide surgical field is necessary. We have reported on the application of a facial dismasking flap for removals of craniofacial lesions in order to provide a better surgical field with less morbidity. In this paper, we are introducing a new method, which is called the "nasal downward swing approach". METHODS: This approach is a modification of the facial dismaking flap, which elevates the nasal bone along with the facial skin. RESULTS: This approach offers an extremely wide surgical field on the facial front, especially the nasal cavity, while keeping scarring or facial paresis down to a bare minimum. CONCLUSION: This approach helps to preserve the entire shape of the nasal bone in particular, therefore, a good surgical option for pediatric patients.

Quantitative analysis of mRNA in human temporal bones.

CONCLUSION: Well-preserved mRNA could be extracted from frozen human inner ears. Therefore, this study demonstrates that analysis of mRNA could be performed to study the molecular mechanisms of inner ear disorders using human specimens. OBJECTIVES: Analysis of RNA as well DNA is requisite to study the molecular mechanisms of inner ear disorders. Methods of isolating RNA from experimental animals have been established, while isolation of RNA from human inner ears is much more challenging. In the present study, we demonstrate a method by which messenger RNA (mRNA) was extracted from human inner ears and quantitatively analyzed. MATERIALS AND METHODS: COCH mRNA as well as GAPDH mRNA was extracted from membranous labyrinths dissected from three formalin-fixed and three frozen human temporal bones, removed at autopsy. The length of COCH mRNA and quantity of GAPDH mRNA was compared between the two groups by quantitative RT-PCR. RESULTS: COCH mRNA could be amplified as much as 976 bp in all three frozen specimens. By contrast, it was amplified to 249 bp in two of the three formalin-fixed specimens, with no amplification observed in the remaining. The quantity of amplifiable GAPDH mRNA in the formalin specimens was only 1% of that of the frozen specimens.

Facial dismasking flap for removal of tumors in the craniofacial region.

OBJECTIVE: This study was aimed at estimating the usefulness of the facial dismasking flap for craniofacial surgery. STUDY DESIGN: Anatomical study and retrospective case study. MATERIALS AND METHODS: The facial dismasking flap is a combination of a coronal skin incision and a circumpalpebral incision. By adding a circumpalpebral incision, the skin can be detached from the orbital structures and the coronal skin flap can be elevated more inferiorly together with the facial nerves and muscles. We retrospectively reviewed patients who underwent the facial dismasking flap with regard to the extent of the surgical field and resectability under this flap. Postoperative facial scarring and movements were also evaluated. Facial palsy was estimated according to the House-Brackmann grading system. RESULT: Twenty-three patients with tumors in various locations, such as, the nasal cavity, paranasal sinus, zygoma, and infratemporal fossa, who had undergone a facial dismasking flap, were studied. Sufficient surgical fields were obtained for removal of the tumor in all patients. Tumors were totally resected in 21 patients and were subtotally resected in two patients to avoid optic nerve damage. Facial nerves were anatomically preserved and facial scarring was minimal in all patients. No facial palsy remained in any patients except one who showed a deterioration of the facial palsy (House-Brackmann grade V-VI). CONCLUSION: This flap allows the surgeon to obtain wide exposure of the upper two-thirds of the facial skull. Moreover, damage to the facial skin is minimal and facial movements are well preserved. This technique is not well known to head and neck surgeons, and this is the first comprehensive report of this technique applied to removal of craniofacial lesions.

Clinical characteristics of audio-vestibular impairment in Ménière's disease: does vestibular function deteriorate in accordance with cochlear function?

The clinical course of Ménière's disease and the outcomes of functional examinations were found to be correlated, and a difference was found between the progressions of vestibular and cochlear dysfunction. Neither the total number of definitive vertiginous spells nor the duration of illness correlated significantly with the degree of audio-vestibular dysfunction. In contrast, frequent vertiginous spells were clearly associated with preservation of audio-vestibular function. Moreover, the clinical characteristics of those patients who experienced less than one definitive vertiginous spell per year were distinct from those of other patients, although both groups showed the typical symptoms of Ménière's disease.

[Minocycline sclerotherapy for lymphorrhea following neck dissection].

Postoperative cervical lymphorrhea is a complication uncommonly encountered following neck dissection for which several treatment modalities have been described in the literature. We managed 8 cases of lymphorrhea after neck dissection by injecting Minocycline through a drainage tube. We attempted this procedure for lymph discharge that had continued despite pressure dressing and systemic management with nutritional modification for about 1 week. This treatment rapidly resolved lymph discharge in 6 of the 8 cases. No patient required surgical intervention. Minocycline sclerotherapy has typically been used to treat pleural effusion, ascites, pneumothorax, and other cystic diseases of the liver, pancreas, and kidney. In many cases, this therapy brings rapid resolution. This inefficiency is due to the acidity and toxicity of Minocycline. No major adverse effects have been reported. We believe that Minocycline sclerotherapy is effective for rapidly resolving lymphorrhea following neck dissection and use of this therapy should be attempted before surgical intervention.