[A case of mycotic pseudoaneurysm of the external carotid artery following a peritonsillar abscess].

Mycotic pseudoaneurysm is a rare complication of deep neck infection. We report herein on a case of mycotic pseudoaneurysm of the external carotid artery following myelodysplastic syndrome and a peritonsillar abscess. The patient was a male in his 60s, who complained of a sore throat and swelling of the left side of his neck. CT scan of the neck showed a left peritonsillar abscess and a pseudoaneurysm of the left external carotid artery. To correspond to airway obstruction in the event that the pseudoaneurysm might rupture to the pharyngeal space, the patient was transferred to our hospital. Surgical management was not selected, since MRI taken just after the admission to our hospital demonstrated remission of the pseudoaneurysm by organization of the structure and decrease of the blood flow. An antibacterial drug and an antifungal drug, SBTPC and VRCZ, were administered to the patient, the inflammatory signs reduced and the size of the pseudoaneurysm gradually diminished without sequela. These findings strongly suggest the importance of controlling the initial neck infection by administration of appropriate antibacterial and/or antifungal drugs to avoid the expansion of the mycotic pseudoaneurysm. Furthermore, MRI was useful to assess the state of the lesion and to determine the way of management.

[A case of propranolol therapy for infantile capillary hemangiomas of the parotis].

A 4-month-old healthy female infant presented with rapid onset of subaural swelling over a three-month period. A head and neck exam demonstrated a subaural elastic hard mass with a red birthmark below the left auricle. MRI of the neck demonstrated a well-defined parotid mass consistent with a haemangioma. We treated this infant with 1 mg/kg of propranolol, which was gradually increased over two months to a dose of 2 mg/kg daily. The tumor began to reduce in size within three days after drug administration, and became less prominent in one month, and had almost totally disappeared within four months. On ten-month follow-up, the patient was asymptomatic and repeated MRI demonstrated further regression of the tumor. Propranolol could be the first-line choice for treating haemangioma rather than simple

Pneumococcal peptidoglycan-polysaccharides regulate Toll-like receptor 2 in the mouse middle ear epithelial cells.

Toll-like receptor 2 (TLR2) plays a key role in the host defense against Gram staining positive (Gram) bacteria and their cell wall envelope components. However, little is known about the expression of TLR2 in the middle ear under otitis media (OM) conditions, and its role in the persistent otitis media with effusion (OME). In this study, we demonstrated that the pneumococcal cell wall component, peptidoglycan-polysaccharides (PGPS), activated the expression of TLR2 in the middle ear epithelial cells through the nuclear factor kappa B (NF-κB)-cytokine signaling pathway while I kappa B alpha mutant (IκBαM), a dominant negative inhibitor of NF-κB, abrogated the expression of TLR2 induced by PGPS. This study suggests that the existence of residual PGPS may maintain a low profile of cytokine production in the middle ear mucosa and thus contribute to the pathogenesis of OME.

Ossiculoplasty with a cartilage-connecting hydroxyapatite prosthesis for tympanosclerotic stapes fixation.

Many cases of tympanosclerotic stapes fixation are accompanied by fixation or erosion of malleus and/or incus. This status of the ossicular chain is one of the reasons that ossiculoplasty for tympanosclerotic stapes fixation is more difficult than that for otosclerosis. We conducted a retrospective review of seven patients who were operated on for tympanosclerotic stapes fixation between 2002 and 2006. All of the patients had abnormal conditions of the malleus and/or incus and underwent stapedectomy and total ossiculoplasty with hydroxyapatite prosthesis (Apaceram T-7 type), which has a planar-like head portion that contacts a piece of cartilage. Postoperative hearing results were assessed in all seven patients after at least 1 year. The postoperative air-bone gap (ABG) was closed within 10 dB in two of seven patients, and was less than 20 dB in six of seven patients. The mean postoperative ABG was closed within 10 dB at 1 and 2 kHz and less than 20 dB at low frequencies (0.25 and 0.5 Hz). There was almost no hearing improvement at high frequencies (4 and 8 kHz). There were no patients with postoperative sensorineural hearing loss. The present study shows that stapedectomy and total ossiculoplasty with cartilage-connecting hydroxyapatite prosthesis is effective and safe for stapes fixation accompanied by fixation or erosion of the malleus and/or incus.

Pneumoperitoneum recurring concomitantly with asthmatic exacerbation.

We report a patient with pneumoperitoneum that recurred concomitantly with asthmatic exacerbation. The patient was a 71-year-old man with a medical history of bronchial asthma. Chest X-rays obtained during asthmatic exacerbation showed intra-abdominal air beneath his diaphragm. Subsequently, a computed tomography scan of his chest confirmed mediastinal emphysema and intra-abdominal air beneath his diaphragm. The intra-abdominal air disappeared after his asthmatic exacerbation was relieved by treatment. The patient showed recurrent pneumoperitoneum concomitant with asthmatic exacerbation. The cause of his pneumoperitoneum was conjectured to be the movement of air from the mediastinum to the peritoneal cavity through the sternocostal triangle.

[Value of diffusion-weighted MR imaging in the detection of middle ear cholesteatoma].

OBJECTIVE: This study, was conducted to determine the clinical value of diffusion-weighted MR imaging (DWI) in detecting the presence of cholesteatoma. SUBJECT AND METHODS: Fifty-six patients (21 female and 35 male patients; mean age, 43 years) who underwent middle ear surgery were referred to the radiology department for a preoperative DWI study. RESULTS: DWI depicted 41 out of 48 cholesteatomas involving the middle ear cavity (sensitivity, 85.4%). Seven patients with middle ear cholesteatoma who showed negative DWI findings (false-negative cases) had limited keratin accumulation due to simple atelectasis or meticulous evacuation of keratin debris before the MRI study. No falsepositive cases were found in this study (specificity, 100%). The positive predictive value and negative predictive value were 100% and 53.3%, respectively. The minimum size of middle ear cholesteatoma detected by the current MRI system was 5mm. CONCLUSION: Diffusion-weighted MR imaging was useful for the detection of middle ear cholesteatoma.

Pneumococcal peptidoglycan-polysaccharides induce the expression of interleukin-8 in airway epithelial cells by way of nuclear factor-kappaB, nuclear factor interleukin-6, or activation protein-1 dependent mechanisms.

Cell envelope compounds of bacteria trigger immune and inflammatory reactions by way of chemokines/cytokines. In this study, we demonstrated that pneumococcal peptidoglycan-polysaccharides (PGPS) induced the production of interleukin (IL)-8 by way of nuclear factor (NF)-kappaB, nuclear factor interleukin (NF-IL)6, and activation protein (AP)-1 dependent mechanisms in the human bronchial epithelial cells (NL-20) in a dose- and time-dependent manner in vitro, and the mutation of either the NF-kappaB, NF-IL6, or AP-1 binding sites in the promoter of IL-8 abrogated the IL-8 transcriptional activity. In a similar way, lipopolysaccharides induced the promoter activation of IL-8 in NL-20. However, the PGPS-induced IL-8 promoter activation in rodent middle ear epithelial cells required NF-kappaB and NF-IL6 but not AP-1.

[Case of lung edema occurring as a result of inhalation of fumes from a Teflon-coated flying pan overheated for 4 hours].

The patient was a 59-year-old man who had been treated with continuous positive airway pressure for a diagnosis of obstructive sleep apnea syndrome. While cooking buckwheat noodles, the patient fell asleep with a frying pan on the fire. After four hours, he was awakened by the smell of burning as well as pharyngalgia, and visited this hospital. He was found to have hypoxia, and diagnostic imaging showed diffuse concentration increase with peripheral clear zones in bilateral lung fields, a typical finding of pulmonary edema. In view of the peculiar temporal course of his disease and inhalation of Teflon fumes immediately before its occurrence, he was considered to have polymer fume fever with non-cardiogenic pulmonary edema. After admission, he was treated with oxygen inhalation and diuretics, and experienced a rapid improvement of his general condition and findings on diagnostic imaging. In European countries and the United States, cases with a history of inhalation of Teflon fumes have been given a diagnosis of polymer fume fever. This case is of interest as it is apparently the first such disease reported in Japan.

Preservation of the auditory nerve function after translabyrinthine removal of vestibular schwannoma.

OBJECTIVE: To evaluate the function of the postoperative auditory nerve preserved after translabyrinthine (TL) vestibular schwannoma (VS) removal. METHODS: Fifteen patients, who underwent unilateral VS resection via a TL approach, were preserved auditory nerve anatomically. The size and location of VS were measured on MRI preoperatively. After surgery, the electrical stimulation test (EST) or electrically evoked auditory brainstem response (EABR) was performed. RESULTS: Four cases (27%) out of fifteen patients were retained the functional integrity of the auditory nerve after surgery. The maximum tumor size in the group with a positive response to EST or EABR was significantly smaller than that in the group with a negative response to EST. It seems to be difficult to preserve auditory nerve function in cases where a tumor extends to the fundus of internal auditory canal. CONCLUSION: These results suggest that size of tumor and/or extension of tumor to the fundus might be important factors in preserving the auditory nerve function even if using a TL approach.

Expression of the integrin genes in the developing cochlea of rats.

Integrins play an important role in the development of the cochlea. However, little is known about the expression pattern of integrins in the developing cochlear tissue. In this study, we investigated the dynamic expression profile of the integrin genes in the developing cochlear tissue of rats by Affymetrix microarrays and explored the role of the integrin genes in vitro by using antisense oligonucleotides. It was demonstrated that the alpha1, alpha7, alphav, beta3, and beta4 genes were expressed in the developing cochlear tissue of rats. Inhibition of the integrin expression with antisense oligonucleotides against alphav, alpha7, beta3, and beta4, respectively, in cochlear sensorineural epithelial cells significantly decreased the [3H]thymidine incorporation, suggesting that these integrins are involved in cell growth and proliferation. Inhibition of the alphav and beta4 integrins significantly decreased the transcription of nuclear factor-kappa B (NF-kappaB, a signal molecule involved in cell growth and proliferation) induced by epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF), respectively. It suggests that EGF-induced cell growth is dependent upon the alphav integrin whereas bFGF-induced cell growth is dependent upon the beta4 integrin in the cochlear tissue during the development of the inner ear.

Temperature-sensitive SV40-immortalized rat middle ear epithelial cells.

The proliferation and differentiation of middle ear epithelial cells are essential in both normal and diseased middle ears. The normal situation involves physiologic growth and renewal of the epithelium, and the diseased situation involves pathological changes of the epithelium such as mucous cell metaplasia and ciliated cell proliferation in otitis media. In this study, we used a temperature-sensitive large T antigen (the SV40 mutant) to transduce and immortalize the primary culture of middle ear epithelial cells. SV40-immortalized middle ear epithelial cells have been cultured for more than 50 passages and are stable morphologically. Their nonimmortalized parent cells died at the second passage. Immortalized middle ear epithelial cells carrying the SV40 mutant show a monolayer, cobblestonelike morphology. The cell line expresses characteristic middle ear mucosal molecules such as mucins, keratins, and collagens. It also responds to temperature changes; namely, cells proliferate at 33 degrees C, when the SV40 antigen is active, and differentiate at 39 degrees C, when the SV40 antigen is inactive. Therefore, we conclude that a temperature-sensitive middle ear epithelial cell line has successfully been established.

[Tracheoesophageal puncture with tracheal tube and flexible endoscope].

Tracheoesophageal shunt phonation is one method of voice restoration after total laryngectomy. Singer and Blom reported an endoscopic technique for voice restoration after laryngectomy, but this is not easy for all cases, because introducing nonflexible endoscope is difficult due to of scarring in the neck and reconstruction with free jejunum. We conducted tracheoesophageal puncture with a tracheal tube and flexible endoscope, finding this useful for all cases of secondary shunt procedures.

Expression of mucins in mucoid otitis media.

A hallmark of mucoid otitis media (MOM, i.e., chronic otitis media with mucoid effusion) is mucus accumulation in the middle ear cavity, a condition that impairs transduction of sounds in the ear and causes hearing loss. The mucin identities of mucus and the underlying mechanism for the production of mucins in MOM are poorly understood. In this study, we demonstrated that the MUC5B and MUC4 were major mucins in MOM that formed distinct treelike polymers (mucus strands). The MUC5B and MUC4 mRNAs in the middle ear mucosa with MOM were up regulated 5-fold and 6-fold, compared with the controls. This upregulation was accompanied by the extensive proliferation of the MUC5B- and MUC4-producing cells in the middle ear epithelium. Further study indicated that the mucin hyperproduction was significantly linked to CD4+ and CD8+ T cells and/or CD68+ monocyte macrophages. It suggests that MUC5B and MUC4 expression may be regulated by the products of these cells.

[The platelet-sparing effect of carboplatin and docetaxel combination chemotherapy for lung cancer].

Paclitaxel and carboplatin chemotherapy is reported to be a platelet-sparing drug combination. The objective of this study was to elucidate whether docetaxel with carboplatin has a similar platelet-sparing effect. This study investigated the time-course of the changes in the platelet count and the circulating concentration of thrombopoietin (TPO), a platelet growth factor, during combination chemotherapy consisting of carboplatin and docetaxel. Eleven patients with advanced lung cancer were enrolled; 8 receiving carboplatin and docetaxel (docetaxel group), and 3 receiving carboplatin and irinotecan (irinotecan group). The time-course profiles of the platelet count and the circulating TPO concentration were determined and compared between the two groups. The platelet count decreased significantly only in the irinotecan group, and on day 15 after therapy the thrombocytopenia was pronounced in comparison with that in the docetaxel group. The circulating TPO concentration remained almost constant in the irinotecan group, with no significant increases, while that in the docetaxel group was increased significantly on day 4 (p < 0.05), day 8 (p < 0.05), and day 15 (p < 0.01) after therapy. There was also a significant difference between the docetaxel group and irinotecan group with respect to circulating TPO concentration (p < 0.05). These results suggest that docetaxel might also have a platelet-sparing effect on the anti-platelet activity of carboplatin, mediated by levels of circulating TPO concentration.

[A phase I study of gemcitabine and irinotecan as second line treatment for advanced non-small cell lung cancer].

A phase I study was conducted to determine the maximum tolerated dose (MTD) and the dose limiting toxicity (DLT) of gemcitabine and irinotecan combination therapy as second line treatment in patients with advanced non-small cell lung cancer (NSCLC). Twelve patients with measurable NSCLC (age range 46-74 years; 7 males, 5 females; performance status 0 = 4, 1 = 8) who progressed or failed first-line chemotherapy were enrolled. Prior chemotherapy was platinum-based without gemcitabine or irinotecan. Gemcitabine was administered at a fixed dose of 1,000 mg/m2 after irinotecan administration, and irinotecan was administered at doses from 50 to 125 mg/m2 with an increment of 25 mg/m2, both on day 1 and 8. Chemotherapy was repeated every 3 weeks. Grade 3/4 leukopenia occurred in three patients (25%), neutropenia in four (33%), anemia in one (8%), and thrombocytopenia in one (8%). Grade 3 nausea and vomiting was observed in three (25%), grade 2 diarrhea in one (8%), and liver dysfunction in one (8%). Other toxicities were mild. Two of the three patients at level 4 (irinotecan 125 mg/m2) experienced dose limiting toxicity: one patient experienced grade 4 leukopenia and neutropenia, and the other experienced treatment delay of more than 2 weeks. The objective response rate was 16.6% (2/12). The maximum tolerated dose in this combination therapy was gemcitabine 1,000 mg/m2 and irinotecan 125 mg/m2. The dose level of gemcitabine 1,000 mg/m2 and irinotecan 100 mg/m2 on day 1 and 8 of a 3-week cycle is recommended for a phase II study.

[A case report of tuberculous pleuritis diagnosed by thoracoscopy using fiberoptic bronchoscope].

A 27-year-old male visited the outpatient clinic of our hospital with the chief complaints of fever, right chest pain and shortness of breath. He was admitted to our hospital for detailed examination of the right hydrothorax. The pleural effusion obtained by thoracocentesis was exudative and negative for Mycobacterium tuberculosis. Since the titer of adenosine deaminase in the pleural effusion was abnormally high, antitubercular therapy was started under suspicion of tuberculous pleuritis. Thereafter, the patient's subjective symptoms and blood parameters improved. Necrotic tissues were obtained by pleural biopsy using the Cope needle. In order to make a definitive diagnosis, pleural biopsy was performed thoracoscopically. White tubercular lesions with a smooth surface were sparsely distributed on the pleura. Histopathologically, these lesions were characterized by central areas of caseous necrosis surrounded by epithelial cells and Langhans' giant cells. Therefore, they were considered to be granulomatous lesions. The patient was given a diagnosis of idiopathic tuberculous pleuritis, and was treated with four antitubercular drugs in combination. His clinical signs subsided, and he was discharged. This case indicates that the examination of the inside of the pleural cavity with a flexible bronchoscope, instead of thoracoscope, under local anesthesia is useful to diagnose patients having tuberculous pleuritis.

[A clinical study of tuberculous pleurisy].

A clinical study of 38 patients (28 men and 10 women) with tuberculous pleurisy was conducted. The age of these patients ranged from 19 to 92 years, with an average age of 48.9 years. In 30 patients, the chief complaint was fever, and other common complaints included chest pain, dyspnea, and coughing. Bacillus tuberculosis was found in the pleural fluid of 7.9% of the patients. Tuberculous pleurisy was diagnosed histologically, based on pleural biopsy, in 23.7% of the patients. The diagnosis rate of pleural biopsy was 47.4%. There were no significant differences in results of blood and pleural fluid tests between idiopathic pleurisy and concomitant pleurisy, but the tuberculin skin test was positive in only 50% of the patients with concomitant pleurisy. The tendency was that the longer the time period between symptom onset and first examination, the greater the pleural fluid retention. The diagnosis rate of pleural biopsy was influenced by the severity of pleural fluid retention. A thoracic cavity drain was inserted for continuous drainage in 15 patients, and every patient underwent INH + RFP-based chemotherapy. Tuberculous pleurisy is an important disease among patients with pleural fluid retention, thus clinicians need to know how to treat this disease.