Hiromi Kanazawa

Reversible cochlear function with ANCA-associated vasculitis initially diagnosed by otologic symptoms.

Objective To present 8 cases with hearing loss as an initial symptom of antineural cytoplasmic antibody (ANCA)–associated vasculitis (AAV) involving granulomatosis with polyangiitis (GPA) and to discuss the treatment and mechanisms of hearing outcomes after immunosuppressive therapy. Study Design Retrospective case review. Setting Tertiary referral center. Patients Eight patients were referred to our university hospital between 2004 and 2012 for intractable otitis media with acute progressive mixed (conductive and sensorineural) hearing loss and facial palsy. Intervention(s) Diagnostics and treatment. Main Outcome Measures Otologic symptoms as initial manifestations of otitis media with AAV and cochlear function after treatment. Results Eight cases (6 female and 2 male subjects; aged 54–73 yr; 6 MPO [myeloperoxidase]–ANCA-positive and 2 PR3 [proteinase 3]–ANCA-positive cases) were included. Progressive hearing loss was present in all patients, and facial palsy was present in 5 of 8 patients total. Patients with hearing levels better than 95 dB improved with good speech discrimination after immunosuppressive therapy, but the completely deaf could not be recovered. All patients have been successfully controlled for 1 to 8 years without any systemic disorders. Conclusion This study showed the difficulty of diagnosing localized AAV and the effectiveness of immunosuppressive therapy for hearing loss in the early stage. Based on these results, early-stage AAV would influence the stria vascularis in the cochlea. Otitis media with ANCA-associated vasculitis is a new entity among the causes of intractable otitis media and progressive hearing loss.

Effect of omalizumab on biomarkers in middle ear effusion in patients with eosinophilic otitis media

Abstract Conclusions: Eosinophil cationic protein (ECP) concentrations in middle ear effusion (MEE) in patients with eosinophilic otitis media (EOM) were significantly decreased at 3 months after the administration of omalizumab from the baseline level (p < 0.05). This study provides new evidence that omalizumab reduces eosinophilic inflammation in the middle ear and that the reduction of ECP may not be caused by suppression of interleukin (IL)-5 production in the middle ear mucosa. Objective: EOM is an intractable otitis media characterized by a highly viscous effusion containing eosinophils. We recently reported that anti-IgE therapy using omalizumab was efficacious in the treatment of EOM. To clarify the underlying mechanism, we determined changes in biomarkers in MEE related to eosinophilic inflammation after therapy. Methods: Nine patients with EOM received the anti-IgE agent omalizumab for 3 months. Among them, five patients continued anti-IgE therapy for longer than 1 year. Eight EOM patients without administration of omalizumab were also included in the study as controls. The concentrations of eosinophilic inflammatory markers such as ECP, IgE, IL-4, and IL-5 in MEE were measured before and after the administration of omalizumab. Results: After 3 months of omalizumab therapy, the ECP concentration in MEE was significantly reduced from the baseline level (p < 0.05), while no significant change of ECP in the serum was observed. The concentrations of IL-4 and IL-5 in MEE showed no significant change before and after the therapy in EOM patients treated with omalizumab.

A comparison of patterns of disease extension in keratosis obturans and external auditory canal cholesteatoma.

Objective To investigate the different pathways of progression to the middle ear in keratosis obturans (KO) and external auditory canal cholesteatoma (EACC). Study Design Retrospective case review. Setting Referral hospital otolaryngology department. Patients Patients with KO or EACC and middle ear disease who underwent surgical management were included. Four ears of 4 patients (mean age, 41.25 yr) were the KO group, and 5 ears of 4 patients (mean age, 49.5 yr) were the EACC group. Main Outcome Measures Intraoperative findings of the middle ear cavity were investigated in KO and EACC groups. Results In the KO group, 3 patients had a perforated tympanic membrane and cholesteatoma in the tympanic cavity. The other patient had preoperative right facial palsy. Removal of the keratin plug revealed an adherent tympanic membrane. In intraoperative findings, the tympanic segment of the fallopian canal was found to be eroded because of inflammation. No case initially progressed to the mastoid cavity. Four patients had external auditory canal cholesteatoma with middle ear disease. In EACC group, all patients had initial progression to the mastoid cavity. Conclusion KO tends to progress initially to the tympanic cavity via a diseased tympanic membrane. EACC tends to progress to the mastoid cavity via destruction of the posterior bony canal. This is the first report to investigate differences in pathway of progression to the middle ear cavity in these 2 diseases.

A comparison of preoperative characteristics of chronic otitis media in Down and non-Down syndrome.

Objective To investigate preoperative clinical findings of chronic otitis media (COM) in patients with Down and without (non-Down) syndrome. Study Design Retrospective. Setting Referral hospital, otolaryngology department. Patients Patients with COM who underwent tympanoplasty were included. There were 10 ears of 8 patients (mean age, 14.9 yr) in the Down group and 44 ears of 41 patients (mean age, 14.7 yr) in the non-Down group. Main Outcome Measures Clinical characteristics, including the frequency of preoperative persistent otorrhea, cause of COM, and mastoid pneumatization (maturation), were compared between the 2 groups using clinical records and temporal bone computed tomography (CT). Results Preoperative persistent otorrhea was more frequent in the Down group (60%) than in the non-Down group (27.2%; p < 0.05). Perforation due to tympanostomy tube insertion also occurred more frequently in the Down group (100%) than in the non-Down group (53.3%; p < 0.05). Mastoid pneumatization occurred significantly less in the Down group than in the non-Down group (p < 0.01). There was no significant difference in mastoid pneumatization regardless of the presence or absence of a past history of tympanostomy tube insertion in the Down group (p = 0.3, t test) unlike that in the non-Down group (p < 0.05, t test). All ears attained a dry condition with no perforated eardrums. Conclusion Frequent draining ear and extremely immature mastoid pneumatization, regardless of the presence or absence of a past history of tympanostomy tube insertion, were clinically important characteristics of COM in patients with Down syndrome.

Clinical Characteristics of Chronic Perforated Otitis Media in Different Age Groups

OBJECTIVE We aimed to analyze preoperative and intraoperative clinical characteristics of chronic perforated otitis media by patient age. MATERIALS AND METHODS We analyzed 137 tympanoplasties for chronic perforated otitis media in 133 patients. Exclusion criteria were ear adhesions, cholesteatoma, and a history of tympanoplasty. Patients were divided into a younger group (aged 15-39 years), a middle group (40-64 years), and an elderly group (≥65 years). We compared tympanoplasty technique (using Wullstein classification), mastoid air-cell area measured by temporal bone computed tomography, preoperative aeration of the temporal bone, mean preoperative hearing (at 500 Hz, 1000 Hz, and 2000 Hz), and patch effect calculated by the pre- and post-patch air-bone gap at frequencies of 250 Hz and 500 Hz among the three age groups. RESULTS Although type I tympanoplasty was performed most frequently in all age groups, it was performed significantly less often in the elderly group (p<0.05). The mean mastoid pneumatization index was significantly lower in the elderly group (p<0.05). Preoperative air-conduction hearing and bone-conduction hearing differed significantly among age groups (p<0.05 for both). There were no significant differences in the air-bone gap among the three groups. The mean patch effect was significantly better in the younger group than in middle or elderly groups (p<0.05). CONCLUSION The less pneumatized mastoid and ossicular diseases in elderly patients with chronic perforated otitis media suggest that they had longer lasting and more severe childhood middle ear pathologies than did younger patients.

A missing denture

Correspondence to: Dr Atsunobu Tsunoda at.hns@tmd.ac.jp A 63-year-old-man with hemiparesis and mild dementia secondary to a cerebral infarction developed sudden haematemesis. He lived in a nursing home and usually ate soft food. After removal of his dentures, we found a pink and white mass on the pharyngeal wall posterior to the palatine arch (figure). With a laryngeal fibrescope we identified a foreign object impacted on the epiglottic vallecula. It was safely removed under local anaesthesia and was found to be another denture. The patient had lost a denture 3 years previously that he and the nursing home staff had been unable to find. He had worn new dentures since then, with the missing denture causing no symptoms in its unorthodox location. A missing denture

Xanthoma in middle ear cavity.

A 1-year-old female patient was referred to our hospital with a history of otitis media of more than 6 months’ duration. Otoscopic findings revealed a whitish mass behind the intact eardrum. On computed tomographic scan, aeration in the middle ear cavity was poor, and involvement of the ossicles was suspected. From these findings, the presence of congenital cholesteatoma was highly suspected. When the patient was 2 years old, she reached adequate body weight for general anesthesia, and we performed tympanoplasty to remove the mass. During the operation, a soft, yellow mass was visualized on the promontory, extending to the attic and also surrounding the ossicles. On intraoperative histologic examination, the expected cholesteatoma was not identified, so we removed the yellow mass as much as possible, while preserving the ossicular chain. Instead, histopathologic examination of the yellow mass showed fibrosis and degenerated foamy cells infiltrated by lymphocytes, which is compatible with xanthoma (Fig. 1).