Dupilumab improves eosinophilic otitis media associated with eosinophilic chronic rhinosinusitis.

BACKGROUND: Eosinophilic otitis media (EOM) is a refractory condition associated with eosinophilic chronic rhinosinusitis and bronchial asthma. EOM is characterized by type-2 inflammation and is refractory to various treatments. We investigated the efficacy of dupilumab, interleukin-4 receptor alpha antagonist, for patients with EOM complicated by eosinophilic chronic rhinosinusitis (ECRS). METHODS: Between April 2017 and April 2022, we treated 124 patients with dupilumab for refractory CRS or bronchial asthma. Of these, 14 had EOM concurrently, and 10 of them who had been treated for >6 months were included in our study. We retrospectively evaluated the efficacy of dupilumab by the amount of systemic corticosteroid used, the frequency of exacerbations, severity score of EOM, computed tomography (CT) score of temporal bones, and pure tone audiometry. We also enrolled 8 EOM patients without dupilumab treatment as a control group. RESULTS: Dupilumab significantly improved the amount of systemic corticosteroid used and the frequency of exacerbation and compared with before dupilumab was used (p = 0.01 and <0.01, respectively). All patients could be weaned from systemic-corticosteroid therapy by 54 weeks of dupilumab use. The severity score of EOM and CT score for temporal bones were significantly lower than before the treatment (p = 0.01 and 0.01, respectively). Compared to the control group, the systemic corticosteroid used and severity scores were improved in the dupilumab group (p = 0.02 and < 0.01, respectively). CONCLUSIONS: Dupilumab could be used to wean patients from systemic corticosteroids with the improvement of severity score in EOM associated with ECRS and bronchial asthma.

Ten-year adherence to continuous positive airway pressure treatment in patients with moderate-to-severe obstructive sleep apnea.

PURPOSE: This study aimed to evaluate the 10-year adherence to and identify the predictors of dropout from continuous positive airway pressure (CPAP) treatment for patients with moderate-to-severe obstructive sleep apnea (OSA). METHODS: We retrospectively analyzed the continuity, dropout, or other behaviors of 181 patients who initiated CPAP treatment at the Tokyo Dental College Ichikawa General Hospital from January 2003 to June 2005. RESULTS: Among a total of 181 patients, 56 (30.9%) dropped out of the treatment. Among the 125 patients who did not dropout, 54 continued CPAP treatment for > 10 years, 16 completed the treatment with OSA improvement, and 7 could not complete the treatment owing to unavoidable reasons such as death, dementia, hospitalization for serious illness, or migration to other countries. Further, 47 patients moved to another facility, whereas 1 patient purchased a CPAP device and stopped visiting our facility. Among the 56 patients who dropped out, approximately 50% of the patients dropped out within a year, and all dropped out within 76 months. Comparing demographics, OSA parameters, and CPAP parameters between the patients who did and did not drop out of the treatment, Cox regression analysis indicated that body mass index (BMI) and the first-month utilization rate were clinical variables that were independently associated with discontinuation of CPAP treatment. CONCLUSION: The results of this study show that BMI and the first-month utilization rate of CPAP treatment are the predictors of the long-term adherence to this treatment.

A new "J septoplasty" technique for correction of mild caudal septal deviation.

OBJECTIVE: A major drawback of the Killian incision is its inability to access the caudal septum and correct caudal septal deviation. Open and hemitransfixion septorhinoplasty are considered necessary in such cases. We developed a new septoplasty method that can be successfully applied in patients with mild caudal septal deviation. In this study, we evaluated the outcome of this technique. METHODS: We prospectively collected data of 16 patients with mild caudal septal deviation who underwent endoscopic septoplasty between November 2015 and October 2017. A modified Killian incision was made on the concave side of the septum. The central part of the cartilage was preserved, and excess cartilage was resected; the central part of the cartilage was sutured to the caudal cartilage. RESULTS: Postoperatively, the ratio of the area of the convex side to that of the concave side in the anterior portion of the nasal cavity was significantly improved, as revealed on CT analysis (p < 0.001). Nasal obstruction was significantly reduced or eliminated in all patients (p < 0.001). CONCLUSION: The J septoplasty method for the correction of mild caudal septal deviation is easy to perform through a modified Killian incision, and seems to be useful in selected cases.

Review of systematic reviews on mandibular advancement oral appliance for obstructive sleep apnea: The importance of long-term follow-up.

The purpose of this review was to present the currently available information on oral appliance (OA) therapy for dentists, especially clinic-based dentists, to aid them in performing this treatment for the management of symptoms of obstructive sleep apnea (OSA). The clinical research evidence comprised of systematic reviews concerned with the mandibular advancement oral appliance (OAm). Continuous positive airway pressure (CPAP) is superior to OA therapy in improving OSA symptoms. It is necessary to survey the adherence of patients who stopped CPAP therapy to OAm therapy. There is little evidence supporting the theory that OAm therapy prevents cardiovascular disease or improves prognosis. There is still room to investigate the types of OAm. OAm therapy has clear dental and skeletal side effects with long-term use, and these are important for dentists. However, a certain percentage of patients discontinue consultations. Regarding consultation rate for follow-up and repair/adjustments of OAm, there are advantages for the clinic-based dentists treating OSA with OAm. We believe that enhancing under-graduate and post-graduate education on sleep medicine, and establishing a specialist system could be the strategies for enabling the dentists to handle OAm therapy in dental clinics.

Validation of a sheet-shaped body vibrometer for screening of obstructive sleep apnea.

We assessed the validity of using a sheet-shaped body vibrometer (SBV) as a portable monitoring device for obstructive sleep apnea (OSA) screening. Seventy consecutive patients with suspected OSA underwent simultaneous in-laboratory polysomnography (PSG) and SBV. We evaluated the screening accuracy of the respiratory event index (REI) obtained with the SBV, using the REI based on either the estimated total sleep time (REI_eTST) or time in bed (REI_TIB); these were compared to the apnea-hypopnea index (AHI) obtained via PSG. Bland-Altman plots indicated that the mean difference between REI_eTST and AHI was lower than that between REI_TIB and AHI (1.2 ± 19.8 vs. 6.5 ± 16.8). For AHI ≥ 15, the sensitivity and specificity at an optimal REI_eTST of 17.0 were 90.9% and 76.9%, whereas those at an optimal REI_TIB of 15.9 were 86.4% and 80.8%, respectively; moreover, for AHI ≥ 30, these values at an optimal REI_eTST of 26.0 were 89.5% and 88.2%, whereas those at an optimal REI_TIB of 23.8 were 84.2% and 92.2%, respectively. The optimal cutoff values of REIs for AHI of ≥ 5 were markedly different from those for AHI obtained via PSG (REI_eTST, 14.9; REI_TIB, 15.0), but close to those for AHI of ≥ 15; both had good sensitivities and specificities. REIs obtained via SBV performed well in moderate-to-severe, but not mild, OSA screening; REI_eTST showed a slightly higher sensitivity and a relatively closer value to the AHI obtained via PSG when compared to REI_TIB. We consider the SBV less acceptable for screening mild cases than more severe cases.

Surfer's ear.

Exostosis in external auditory canal is common among surfers. Common symptoms are decreased hearing or loss of hearing, ear infection, and/or plugging sensation. Repeated exposure to cold water is a key clinical history to suspect this condition. Based on symptoms and existence of infection, surgical removal of the exostosis is recommended.

Eagle syndrome.

Although rare, Eagle syndrome should be always considered in the differential diagnosis in patients with chronic orofacial pain refractory to conventional treatments. Treatment is surgery and exeresis of the styloid process via a transoral or cervical approach depending on clinical and radiological features.

Risk factors for olfactory dysfunction in chronic rhinosinusitis.

OBJECTIVE: Although risk factors for olfactory dysfunction in patients with chronic rhinosinusitis (CRS) have been examined, most studies did not distinguish between classified eosinophilic chronic rhinosinusitis (ECRS) and noneosinophilic chronic rhinosinusitis (NECRS). The incidence of eosinophilic disease in Japan differs from that in the West. Thus, when olfaction in CRS is investigated, ECRS and NECRS should be examined separately. In the present study, we examined the clinical characteristics associated with olfactory dysfunction in Japanese patients with ECRS and NECRS enrolled in a large multicenter, prospective cohort study. METHODS: Olfactory examination results, demographic data, clinical factors, and comorbidity data were analyzed for 418 patients with CRS at 3 tertiary care centers. We used T&T olfactometry, intravenous olfactory test (the Alinamin test) and Likert scale to assess subjects' olfactory function. Data were analyzed with univariate and multivariate analyses. RESULTS: Olfactory dysfunction was more severe and more prevalent in ECRS than in NECRS. We found that olfactory cleft polyps (odds ratio [OR], 3.24), ethmoid opacification (OR, 2.64), asthma (OR, 2.29), current smoking (OR, 1.74) and age ≥50 years (OR, 1.66) were associated with olfactory dysfunction in CRS. Ethmoid opacification (OR, 3.09) and olfactory cleft polyps (OR, 3.05) were associated with olfactory dysfunction in NECRS. Olfactory cleft polyps (OR, 3.98), current smoking (OR, 2.67), IgE ≥400IU/ml (OR, 2.65), ethmoid opacification (OR, 2.51), and asthma (OR, 2.34) were associated with olfactory dysfunction in ECRS. CONCLUSIONS: Olfactory dysfunction was more severe and prevalent in ECRS than in NECRS. Physician should pay attention to these clinical findings to diagnose olfactory dysfunction, especially in ECRS, and should provide appropriate explanation, guidance, and care. In addition, smokers should be advised to stop smoking to help prevent olfactory dysfunction.

Effect of maxillomandibular advancement on morphology of velopharyngeal space.

PURPOSE: The objectives of the present study were to assess the changes in upper airway morphology and function in response to advancement of the maxilla and mandible. PATIENTS AND METHODS: Orthognathic surgery was performed. During the surgery, the maxilla and mandible were each advanced as a maxillomandibular advancement simulation. A total of 18 patients with a chief complaint of malocclusion were studied. The distance in jaw advancement and the anteroposterior and left-right diameters of the velopharyngeal space before and after jaw advancement were measured. After the anteroposterior and left-right dilation rates and area enlargement rates were calculated, we compared advancement of the maxilla with that of the mandible. RESULTS: Each of the jaw advancements resulted in statistically significant increases in the anteroposterior and left-right diameters of the velopharyngeal space, and the area was significantly enlarged. The anteroposterior dilation rate was significantly greater after advancement of the maxilla, and the left-right dilation rate was significantly greater after advancement of the mandible. The velopharyngeal space area enlargement rate was significantly greater with advancement of the maxilla. CONCLUSIONS: These data suggest that the mode of dilation of the velopharyngeal space differs between maxillary advancement and mandibular advancement. Jaw advancement affects the soft palate muscles, and the velopharyngeal space is expanded 3-dimensionally by each of those muscles. The difference in the pattern of expansion of the velopharyngeal space was related to differences in the functions of the soft palate muscles.

Chronic rhinosinusitis: risk factors for the recurrence of chronic rhinosinusitis based on 5-year follow-up after endoscopic sinus surgery.

BACKGROUND: Chronic rhinosinusitis (CRS) is one of the most frequent chronic diseases in the US, and little is understood about its pathogenesis. This study was conducted to characterize, retrospectively, the clinical, objective and immunological parameters that accompany recurrence of CRS during long-term follow-up after surgery. METHODS: Fifty-six patients with CRS who had undergone endoscopic sinus surgery were followed up for 5 years after the surgery. The CRS parameters chosen were as follows: history of asthma and/or allergic rhinitis, peripheral eosinophilia of at least 520 cells/microl, peripheral eosinophil count, total IgE, presence of polyps, CT score, presence of fungi (positive fungal culture or stain), mucus or mucosal eosinophilia, mucosal eosinophil count, presence of acute infection after surgery, gender and age. Individual correlations and stepwise regression were performed. RESULTS: Patients with a total peripheral eosinophil count of 520/microl or more and those with asthma were likely to experience recurrence of CRS within 5 years after surgery. Furthermore, patients with mucus or mucosal eosinophilia who were diagnosed as having eosinophilic CRS (ECRS) showed a high incidence of recurrence within 5 years. The parameter of mucus or mucosal eosinophilia (diagnosis of ECRS) had a positive predictive value of 85.7%. CONCLUSIONS: Surgeons should always examine the inflammatory infiltrate of nasal polyps or the paranasal mucosa, and patients with ECRS require anti-inflammatory medications, such as steroids, for a long time after surgery. Long-term follow-up is also essential.

Can mouthguards prevent mandibular bone fractures and concussions? A laboratory study with an artificial skull model.

Some sports' accidents are responsible for inflicting traumatic brain injuries and mandibular bone fractures when impacts occur to the chin. It is often thought that mouth guards can prevent many of these injuries. However, such assertions may be insufficient without adequate research. It is therefore necessary to establish a systematic method of investigation to solve this problem. In the present laboratory study, tests were performed using pendulum impact equipment and an artificial skull model connected to strain gages and accelerometers to simulate and measure the surface distortions related to bone deformation or fractures and the acceleration of the head related to concussions. As impacts, direct blows to the mandibular undersurface were applied. As a result, wearing a mouth guard decreased (P < 0.01) the distortion to the mandibular bone and the acceleration of the head significantly compared with not wearing a mouth guard (54.7%: to the mandible -- measured at a total of three different points, 18.5%: to the head measured at a total of three different points). Within the limits of this study, the following conclusions were drawn: The present measuring system in this study was able to evaluate the distortion to the mandibular and the acceleration of the head from the direct blow to the mandibular undersurface. Mouth guards can reduce distortion to the mandibular and the acceleration of the head from the same blow. So mouth guards might have the possibility to prevent mandibular bone fractures and concussions. However, further well-designed and exhaustive studies are vital to show that mouth guards reduce the incidence of concussions and mandibular bone fractures.

Relationship between pediatric sinusitis and middle turbinate pneumatization--ethmoidal sinus pyocele thought to be caused by middle turbinate pneumatization.

OBJECTIVE: To investigate whether the presence of pediatric middle turbinate pneumatization causes narrowing of the ostiomeatal complex (OMC) and is associated with the development of paranasal sinusitis. METHODS: CT scans of 190 nasal sides of 95 children (1-15 years old) were analyzed for the presence of middle turbinate pneumatization and mucosal thickness in the paranasal sinus. RESULTS: Middle turbinate pneumatization was detected in nine (4.6%) of the nasal cavities. Only one of these sides was in a patient younger than 10 years of age, while the other eight sides were in patients at least 13 years old. In six of those nine sides with pneumatization, paranasal sinusitis was also found. However, the images showed that in five sides the middle turbinate pneumatization itself did not obstruct the OMC. In addition, the mean +/- standard deviation (S.D.) of the total score for the paranasal sinus opacification on the side which had the middle turbinate pneumatization was 5.67 +/- 2.95. The corresponding value for the 76 sides without pneumatization was 5.29 +/- 2.53, and the difference between these mean total scores was not statistically significant. However, in one side, the OMC was obstructed or narrowed due to the middle turbinate pneumatization, and an ethmoidal sinus pyocele formed on this side. CONCLUSION: A causal relationship was not found between middle turbinate pneumatization and the mechanism of development of paranasal sinusitis in children. However, in the event that the OMU becomes obstructed at some time, frequent cycles of improvement and aggravation of pediatric paranasal sinusitis may occur and lead to the development of a serious condition.

Evaluation of missing fundamental phenomenon in the human auditory cortex.

OBJECTIVE: Harmonic complex tones consisting of four or more continuous harmonics of a certain stem frequency are perceived as the pitch of the fundamental frequency tone, it is referred to as the missing fundamental phenomenon (MFP). It is considered that the MFP is produced in the central auditory system, not in the periphery. However, it remains unclear where and how complex sounds is integrated. Using 306ch magnetoencephalography (MEG), we investigated when and where the MFP was integrated in the auditory cortex. METHOD: We examined six subjects who were selected by MEG in 12 healthy right-handed adult volunteers with normal auditory sensation. Ears were randomly stimulated with five different complex tones consist of fundamental frequency tone and harmonic complex tones. The location and direction of equivalent current dipoles (ECD) were evaluated at P50 and N100 in the right temporal lobe by MEG. Dispersion of the source of ECD was respectively evaluated on their brain MRI. RESULTS: Stimulation of ears with harmonic complex tones and the stem frequency tone revealed the localization of P50 and N100 ECD in the transverse temporal gyrus and their peripheral superior temporal gyrus. Although the sources of P50 ECD for harmonic complex tones and the fundamental tone were varied around the transverse temporal gyrus and superior temporal gyrus, the sources of N100 ECD were almost identical at the transverse temporal gyrus, demonstrating the MFP. This phenomenon were similarly observed, even when dichotic listening were stimulated. CONCLUSION: These findings suggest that the MFP occurs in the transverse temporal gyrus and the superior temporal gyrus, which are the primary auditory cortex, between P50 and N100.

Approach to obstructive sleep apnea syndrome at Tokyo Dental College, Ichikawa General Hospital.

In this communication, we report the current status of OSAS (Obstructive Sleep Apnea Syndrome) in the southern region of Higashikatsushika around Ichikawa City, our effort to improve patient QOL as well as to establish diagnostic and therapeutic methods, and the results of a comparison of therapeutic options with the focus on improvement of compliance by using nCPAP (nasal continuous positive airway pressure). We examined 112 patients who visited the Otolaryngology Department at Tokyo Dental College, Ichikawa General Hospital, with the chief complaint of nocturnal snoring or sleep apnea from January 2001 to April 2003 and underwent all-night PSG (polysomnography). Based upon the results of these all-night PSGs, 89 and 23 patients were diagnosed as having OSAS and simple snoring, respectively. Using the AHI classification of severity, 58 and 31 patients were assessed as having severe OSAS and mild OSAS, respectively. (1) nCPAP was tried in 61 patients, and 39 patients (63%) were able to continue it. After the introduction of nCPAP, surgery was performed in 18 patients (30%). As a result, weaning from nCPAP was successfully achieved in 10 cases, compliance with nCPAP was improved in six cases, alleviation of symptoms (decreased pressure) was seen in one case, and aggravation was noted in one case. In addition, four patients (7%) unilaterally discontinued nCPAP. (2) Surgery was performed in 34 patients, and 18 of them had surgery after nCPAP was tried. (3) We asked the dental department to make OAs (oral appliances) for 31 patients but seven of them did not attend the department, so a total of 24 patients used OAs. Fourteen patients (58%) were able to tolerate an OA for 3 months or more. Based on these results, we are hoping to achieve a better control of OSAS by combining nCPAP and other modalities.

[Allergic fungal sinusitis].

Allergic fungal sinusitis (AFS) is considered an allergic inflammation against fungus, and has been reported to be refractory, with very high recurrence. In Europe and the United States, AFS incidence is reported from 4% to 7% in patients with chronic sinusitis undergoing endoscopic sinus surgery (ESS). In Japan, however, only 5 patients, including ours have been reported, making AFS very rare in Japan. We prospectively studied the incidence, pathogenesis and diagnosis of AFS in Japan among 102 patients with chronic sinusitis who underwent ESS. Four cases (3.9%) were diagnosed with AFS based on the criteria of Bent and Kuhn. This incidence is slightly lower than that reported in Europe and the United States. We report the diagnosis, treatment, and course in 4 AFS patients. Of these, an allergen provocation test against detected fungus was conducted in 2 from whom informed consent was obtained. In the immediate phase, positive reactions were observed. Immunoglobulin E (IgE) antibody-mediated type I allergy may be involved in the pathogenesis of AFS.