Atsuko Takamaki

Residual Cholesteatoma: Incidence and Localization in Canal Wall Down Tympanoplasty With Soft-Wall Reconstruction

OBJECTIVE To compare the incidence and localization of residual cholesteatomas in canal wall down tympanoplasty with soft-wall reconstruction with results with the canal wall down and open tympanoplasty or canal wall up tympanoplasty. DESIGN Retrospective case-series study. SETTING Tertiary care university hospital. PATIENTS Eighty-five patients (85 ears) with fresh extensive cholesteatomas who underwent canal wall down tympanoplasty with soft-wall reconstruction as first-stage surgery and a second operation after 1 year to confirm residual cholesteatomas and perform ossiculoplasty. MAIN OUTCOME MEASURES The incidence and localization of residual cholesteatomas in the middle ear were compared between surgery using the canal wall down and open tympanoplasty and canal wall up tympanoplasty. Possible technical causes of the residua were reviewed in a retrospective videotape analysis of the first-stage operations. RESULTS Of the 85 ears operated on, 18 had residual cholesteatomas, for an overall incidence of 21%, with 1 residuum per ear. Six cholesteatomas were located in the epitympanum (33%), 3 in the sinus tympani (17%), 3 in the antrum (17%), 2 on the stapes (11%), 2 on the tympanic membrane (11%), 1 on the tympanic portion of the facial canal (6%), and 1 just under the skin of the external auditory canal (6%). The retrospective videotape analysis revealed that the main cause of residual cholesteatomas in the epitympanum and sinus tympani was incomplete removal of the matrix under an indirect surgical view because of insufficient drilling. Residual matrix in a bony defect in the middle cranial fossa or facial canal was the cause of residual cholesteatomas in the antrum or facial canal. Inappropriate keratinizing epithelium rolling during tympanic membrane or external auditory canal reconstruction was the cause of residual cholesteatomas in the tympanic membrane or external auditory canal. CONCLUSIONS The incidence of residual cholesteatomas in patients who underwent canal wall down tympanoplasty with soft-wall reconstruction was similar to that in patients who underwent surgery involving the canal wall down and open tympanoplasty or canal wall up tympanoplasty. In terms of localization, with canal wall down tympanoplasty with soft-wall reconstruction, there is the possibility of residua not only in the tympanic cavity but also in the antrum or mastoid cavity, as with the canal wall up method. Results of this study suggest that in patients with extensive cholesteatoma, canal wall down tympanoplasty with soft-wall reconstruction should be followed by a second procedure to detect any residual cholesteatomas in the tympanic cavity, antrum, or mastoid cavity.

Prognosis for Bell's palsy: a comparison of diabetic and nondiabetic patients

Conclusion. The present study indicates that recovery from Bells palsy in a diabetic group (DG) is delayed, and the facial movement score remains low in comparison with a nondiabetic group (NDG). More aggressive treatments, such as higher-dose corticosteroid administration and/or facial nerve decompression surgery, might be considered in diabetic patients with severe Bells palsy. Objectives. The purpose of this study was to reveal prognostic differences for Bells palsy in the DG and NDG. Patients and methods. The grades of facial palsy in 19 diabetic and 57 nondiabetic patients with Bells palsy were assessed using the House-Brackmann grading system (HB system). Recovery was defined as grade I. The average of HB system grades and recovery rates were compared in the DG and NDG at the start of the treatment, and 1 month, 3 months, and 6 months after onset. Results. There were no differences in the HB system between the DG and NDG at the start of treatment and at 1 month after onset. However, facial movement in the DG was poorer than that in the NDG at 3 months and 6 months after onset. In terms of the recovery rate, the rate in the DG (52.6%) was much lower than that in the NDG (82.5%) at 6 months after onset.

Postoperative aeration in the middle ear and hearing outcome after canal wall down tympanoplasty with soft-wall reconstruction for cholesteatoma.

Objective: Canal wall down (CWD) tympanoplasty with soft-wall reconstruction (SWR) is a unique technique for cholesteatoma surgery. The external auditory canal shape after surgery-retracted like a radical mastoid cavity or preserved intact-depends on postoperative aeration in the mastoid cavity. However, the relationship between postoperative middle ear aeration and hearing outcome with this procedure is unknown. We characterized this relationship and propose an ideal state of middle ear aeration to obtain satisfactory postoperative hearing after CWD tympanoplasty with SWR. Study Design: Retrospective case series. Patients: Seventy-eight patients (78 ears) with fresh cholesteatomas treated surgically at our hospital by planned 2-stage CWD tympanoplasty and SWR were included. Main Outcome Measures: Postoperative middle ear aeration was scored 1 year after second-stage surgery by computed tomography. The patients were divided into 4 bins according to postoperative audiometric air-bone (A-B) gaps: 0-10, 11-20, 21-30, and greater than 30 dB. Results: Postoperative middle ear aeration was significantly greater in the smaller gap bins (0-10 and 11-20 dB) compared with the larger A-B gap bins (21-30 and >30 dB). In contrast to the larger A-B gap bins, those with smaller A-B gaps showed reaeration of the antrum and mastoid cavity. No significant differences were observed in postoperative middle ear aeration or hearing outcome between the 2 cholesteatoma types. Conclusion: Promoting postoperative aeration of the entire middle ear is necessary to achieve better hearing outcome in patients undergoing CWD tympanoplasty and SWR for cholesteatoma.

A new method for measuring compound muscle action potentials in facial palsy: A preliminary study

To establish a simple, reproducible procedure for studying facial motor nerve conduction (MNC), we determined the optimal electrode position to record evoked compound muscle action potentials (CMAPs) from perioral muscles in normal subjects. We examined three new electrode positions in which the electrode connected to the one input of the amplifier was placed on the mental protuberance, and the one connected to the other input was placed on the skin over the orbicularis oris muscle (the philtrum, mouth angle, or lower lip). We then compared the morphology and amplitudes of the CMAPs, right–left differences, and the reproducibility of CMAP amplitudes with recordings taken from the standard electrode position in which one electrode was placed on the nasolabial fold closely lateral to the ala nasi, and the other was placed on the skin over the orbicularis oris. Percutaneous supramaximal electrical stimulation was applied to the main trunk of the facial nerve. All three of the new recording positions showed greater amplitudes and more obvious biphasic CMAPs than the standard method. Positioning the electrode connected to the negative input on the philtrum was optimal in terms of right–left differences and the reproducibility of CMAP amplitudes. Therefore, this midline recording is a simple, reproducible method for calculating the CMAP amplitude ratio. However, prior to clinical use of this procedure, analyses of patients with facial palsy are required. Muscle Nerve 37: 764–769, 2008

Lipomatous pleomorphic adenoma of the ceruminous gland

A case of lipomatous pleomorphic adenoma in the ceruminous gland is reported. A 69‐year‐old Japanese woman presented with a mass in the posterior wall of the cartilaginous external auditory canal. Light microscopic examination revealed a well‐circumscribed tumor composed of tubular structures with apocrine secretion and ceroid deposition, extensive mature adipocytes, and spindle‐shaped myoepithelial cells in the myxoid and fibrous stroma. This case demonstrates the peculiar location of a lipomatous pleomorphic adenoma in the external auditory canal.

Ultrasonography for preoperative localization of enlarged parathyroid glands in secondary hyperparathyroidism

OBJECTIVE Parathyroidectomy (PTx) is sometimes performed to treat secondary hyperparathyroidism (2HPT) related to long-term dialysis. In this procedure, all four parathyroid glands should be resected. However, in patients with 2HPT, the four glands are not uniformly enlarged; therefore, preoperative diagnosis is difficult in comparison with primary hyperparathyroidism. We compared glands detected on preoperative ultrasonography (US) with those resected during PTx to examine the usefulness and limitations of US. METHODS The subjects were 44 patients with 2HPT who underwent PTx between December 2003 and November 2007. Surgery was indicated for patients meeting the following three conditions: a serum intact PTH (iPTH) level of 500 pg/ml or more; a maximum glandular volume of 500 mm3 or more; and increased bone metabolism. Before surgery, we detected the parathyroid glands using US, and three-dimensionally measured their sizes. PTx was performed based on US diagnosis, and resected glands were weighed. RESULTS Assuming that four parathyroid glands are present in each patient, the total number of glands in the 44 patients was 176. Of the 176 glands, 139 were detected on preoperative US. However, 27 could not be resected. Therefore, the detection rate on US was 63.6% (112/176). Of 37 glands that could not be detected on preoperative US, 30 were detected during surgery, and resected. There was a positive correlation between the glandular volume measured on US and isolated gland weight. However, there was no correlation between the preoperative serum iPTH level and the sum of the four isolated gland weights. CONCLUSION On preoperative US, approximately 80% of the glands were detected. However, the misdiagnosis rate was approximately 20%. The rate of accurate diagnosis was 63.6%. Even when glands were misdiagnosed or could not be confirmed on preoperative US, approximately 80% of them could be detected and resected during surgery. It may be impossible to estimate the glandular volume based on the preoperative serum iPTH level.

Planned fractionated boron neutron capture therapy using epithermal neutrons for a patient with recurrent squamous cell carcinoma in the temporal bone: a case report.

We describe the first case of extensive squamous cell carcinoma in the temporal bone recurring after surgery, conventional radiotherapy, and chemotherapy, which was treated using planned fractionated boron neutron capture therapy (BNCT).

A novel electroneurography method in facial palsy

CONCLUSION The novel midline electroneurography (ENoG) method may have advantages over the standard method in terms of ease of electrode setting, and the ENoG value may be a useful prognostic factor. OBJECTIVE We compared ENoG performed in patients with facial palsy using two different methods--the new midline method and standard method--in terms of the amplitudes of the compound muscle action potentials(CMAPs) and relationship between the ENoG value and clinical course. METHODS A total of 64 patients with facial palsy were enrolled. CMAPs were recorded using the midline method, in which the recording electrodes were placed on the mental protuberance and philtrum over the orbicularis oris muscle, and the standard method, in which the recording electrodes were set close to the nasolabial fold. Percutaneous electrical stimulation was applied to the main trunk of the facial nerve.The amplitudes of the CMAPs and the relationship between the ENoG value and the period to full recovery from the facial palsy were compared. RESULTS The midline method had larger CMAP amplitudes on both sides and a stronger negative correlation in the relationship between the ENoG value and period to full recovery from palsy than the standard method statistically.

S209 – Optimal Electrode Position for ENoG for Facial Palsy

Objectives To develop a more simple procedure for electroneurography (ENoG) of facial palsy for assessing prognosis, we conducted a preliminary study to examine an optimal electrode position for recording evoked compound muscle action potentials (CMAPs) of the perioral muscles. Methods We evaluated a new method called the submentall method, in which the electrode connected to the negative input (G1) was placed on the skin over the orbicularis oris muscle, and the other electrode connected to the positive input of the amplifier (G2) was placed on the mental protuberance. We compared the amplitudes and morphology between the CMAPs recorded with this method and those recorded using the standard electrode positions (G1 placed on the skin over the orbicularis oris muscle; G2 placed on the nasolabial fold, closely lateral to the ala nasi). Furthermore, the amplitudes and waveforms of CMAPs were recorded from 4 different G1 positions on the skin over the orbicularis oris muscle, with G2 set on the mental protuberance. The main trunk of the facial nerve was stimulated by percutaneous supramaximal electrical stimulation beneath the auricle. Results The submental method gave greater amplitudes and more obvious biphasic CMAPs than those produced with the standard method. In the submental method, the optimal G1 recording electrode position was on the philtrum. Conclusions This recording procedure has the potential to be a simpler and more reliable method for calculating ENoG values than the standard method. However, further studies to establish prognostic criteria of ENoG for facial palsy are needed.

P089: Residual Cholesteatoma: Problems Revealed by Video Analysis

OBJECTIVES: 1. Evaluate the incidence and regions of residual cholesteatoma observed in planned second-stage operations. 2. Reveal inappropriate manipulations performed in first-stage operations leading to residual cholesteatomas by retrospective video analysis. METHODS: Enrolled were 85 ears from 85 patients who underwent planned staged tympanoplasty for extensive cholesteatoma at Osaka Medical College from 2001 through 2006. For cases in which residual cholesteatomas were found at the second stage, videos taken in the first-stage operations were analyzed retrospectively. RESULTS: Eighteen ears had residual cholesteatomas, and the overall incidence was 21%. In terms of regions, 6 cholesteatomas were observed in the epitympanum, 3 in the sinus tympani, 3 in the antrum, 2 on the stapes, 2 in the tympanic membrane, 1 on the tympanic portion of the facial canal, and 1 in the skin of the external auditory canal. With regard to inappropriate manipulations, removal of the matrix under indirect surgical view due to incomplete opening of the attic or insufficient drilldown to the facial canal was considered to be a chief cause of residua. Residua of the matrix in the bony defects of the middle cranial fossa or facial canal and keratinizing epithelial rolling obtained in the event of tympanic membrane reconstruction also were main causes of residual cholesteatomas. CONCLUSIONS: Retrospective video analysis, which is extremely useful to reveal technical problems in first-stage operations leading to residual cholesteatomas, reveals what manipulations we have to do carefully to decrease residua. The incidence and regions of residual cholesteatomas were similar to those in previous reports.