Koshiro Nakamura

Resection of peripheral branches of the posterior nasal nerve compared to conventional posterior neurectomy in severe allergic rhinitis

OBJECTIVE Transnasal resection of the posterior nasal nerve (TRPN) is the surgical procedure for drug therapy-resistant, intractable allergic rhinitis (AR). Submucous inferior turbinectomy also improves nasal symptoms in severe AR. Surgical injury to this peripheral nerve fibre may be the major cause of the decrease in allergic symptoms. During submucous turbinectomy, we have identified the peripheral branches of the posterior nasal nerve in the inferior turbinate and resected them (SRPN). The aim of this study was to evaluate the therapeutic effects of turbinoplasty with SRPN in severe AR. METHODS Improvements in subjective symptoms were compared between 13 patients who underwent SRPN with turbinoplasty (Group 1) and 11 who underwent TRPN combined with turbinoplasty and SRPN (Group 2) by retrospective chart review. Pre- and postoperative sneezing, rhinorrhea, and nasal obstruction were evaluated with questionnaires. Postoperative complications and drug therapy before and after surgery were investigated. RESULTS All symptoms improved postoperatively in both groups, with no significant differences in the improvements in nasal symptom scores between the groups. CONCLUSIONS SRPN combined with submucosal turbinectomy was shown to be a safe, useful, and efficient approach to patients with AR unresponsive to medical therapy. Although this is a short-term study, the results of this study suggest that SRPN represents one of the treatment options for intractable AR.

Parapharyngeal vagal neurilemmoma extending to the jugular foramen

A large vagal neurilemmoma in a 33-year-old man is reported. He complained of slowly progressive palsy of the tongue on the left side. Weakness of soft palate movement was also noted. Magnetic resonance imaging (MRI) revealed a tumour in the left parapharyngeal space with partial extension to the posterior cranial fossa through the jugular foramen. Carotid angiography revealed avascularity of the tumour and anterior shift of the left internal carotid artery. The venous phase showed no blood flow in the internal jugular vein. The tumour was successfully extirpated via a transmandibular transpterygoid approach. Although vagus nerve dysfunction was not observed pre-operatively, the tumour was identified as a neurilemmoma arising from the vagus nerve. The surgical approach should be selected according to the lesion in individual patients. Since neurilemmoma is benign in nature, minimal post-operative sequelae should be expected.

Comments on ‘‘Acoustic transfer characteristics in human middle ears studied by a SQUID magnetometer method’’ [J. Acoust. Soc. Am. 82, 1646–1654 (1987)]

The study by Brenkman et al. [J. Acoust. Soc. Am. 82, 1646-1654 (1987)] of malleus umbo and anterior crus of stapes displacement in 14 human temporal bones shows a mean -7.3-dB/oct slope above 1.0 kHz for stapes displacement in response to a 80-dB SPL input at the eardrum. The slope they obtained for midfrequency (1.0-4.0 kHz) stapes displacement is significantly flatter than what was found previously [Gyo et al., Acta Otolaryngol. 103, 87-95 (1987); Gundersen, Prostheses in the Ossicular Chain (University Park, Baltimore, MD, 1971); Kringlebotn and Gundersen, J. Acoust. Soc. Am. 77, 159-164 (1985); Vlaming and Feenstra, Clin. Otolaryngol. 11, 353-363 (1986a)]; in these studies, stapes displacement rolled off at -12.0 to -14.9 dB/oct above 1.0 kHz. It appears that their mean midfrequency stapes displacement slope has been flattened by some unusual results in a small number of ears. Possible reasons for these results are discussed.

Reconstruction of Carotid Artery in Radical Neck Dissection

No permanent cure of head-and-neck cancer can be expected when the cancer infiltrates into the wall of the carotid artery. When the carotid artery was resected, the resultant hemiplegia poses very difficult postoperative rehabilitation problems, even though the cancer is eradicated. The recent development of vascular surgery has made reconstruction of the carotid artery feasible. In this paper, the authors reported the indications of reconstruction of the carotid artery in radical neck dissections and the surgical procedures. The indication of reconstruction of the carotid artery is determined by using of angiography, CT-scan and echography. Especially, echography is useful for determining the possibility of reconstructing the carotid artery. In the case of the infiltration type, we can start to remove tumor after preparing for the reconstruction of the carotid artery. The principle of surgical procedures consists of by-pass shunt with a vascular graft between the common and internal carotid arteries, excision of the artery with tumor and insertion of a vascular graft with end-to-end anatomoses. Concerning the selection of a vascular graft, an auto-vein graft is preferable to a synthetic graft in consideration of the postoperative patency of the vascular flow. Moreover, in the case of reconstructing the artery, preoperative irradiation has often been applied and a wide removal of the soft tissue is required, so it is recommended that the myocutaneous flap be used to cover the reconstructed area.

Surgical treatment of synkinesis.

Synkinesis is the most troublesome and common sequela seen in the recovery course of facial nerve palsy. However, no appropriate treatment has been developed so far. We used selective neurectomy on two patients with synkinesis and obtained good results; this technique has often been utilized for hemifacial spasm.

Superselective intra-arterial infusion chemotherapy administered through the deep lingual artery and concomitant radiotherapy: ―舌深動脈からの動注―

Superselective intra-arterial infusion chemotherapy administered through the deep lingual artery and concomitant radiotherapy : Yuichi Tomidokoro1), Nobumitsu Honda1), Sohei Mitani1), Taro Takagi1), Eriko Nishihara1), Koshiro Nakamura1) and Toru Ugumori2). 1)Department of Otolaryngology-Head and Neck Surgery, Ehime Prefectural Central Hospital, 2)Department of Otolaryngology-Head and Neck Surgery, Ehime University School of Medicine

Surgical Treatment of Benign Parotid Gland Tumors

The goal of surgical treatment for benign parotid gland tumors is to remove the mass completely without causing facial nerve palsy. In recent years, limited parotidectomy is becoming a new standard procedure for benign tumors, replacing superficial parotidectomy, and excellent results equal to the old procedure are being reported.This study evaluates the postoperative results of 59 benign parotid tumors treated surgically between 1991 and 2001, then determined whether limited parotidectomy can become the new standard of surgical management for benign parotid tumor.In 39 of the 59 patients, we investigated the frequency of local recurrence, Freys syndrome and facial palsy. The histopathological diagnosis was pleomorphic adenoma in 17, Warthins tumor in 15 and miscellaneous tumor including cyst, lymphoepithelial lesion or other lesions in 7, respectively. Twenty-one patients underwent partial parotidectomy, 10 enucleation and 8 superficial parotidectomy, respectively. The postoperative follow-up duration ranged from 3 to 14 years with an average of 7.54 years.According to the results of this follow-up study, there was no recurrence with each surgical procedure. Freys syndrome did not occur in any patient after partial parotidectomy compared to that in 3 patients (37.5%) after superficial parotidectomy. Four patients (19.0%) temporarily experienced in some degree of facial nerve weakness after partial parotidectomy.From these results, partial parotidectomy is thought to be a new trend in the surgical treatment of benign parotid tumor.

Three Cases of Sphenoid Sinus Mycosis

Mycosis in the paranasal sinus is commonly found in the maxillary sinus, but rarely in the sphenoid sinus. In this paper, three cases of sphenoid sinus mycosis are reported and the clinical feature are compared with the 25 other cases reported in Japan since 1968. Our three patients had complained of headache and eye pain, which were thought to be characteristic symptoms in the 25 previous cases. One of the three patients had onset with a background of rheumatoid arthritis and needed steroid medication, but the other two patients had no improvement with medication for sinusitis. By CT scanning and MRI, a localized sphenoid sinus lesion was detected as a characteristic findings for paranasal sinus mycosis, showing irregular mosaic contras on CT scanning and low intensity signal on T1 and T2 MRI imaging. The definite diagnosis was made by means of histological examination for a block age in the affected sinus cavity. Endoscopic sphenoidectomy was performed through the parsnaslis of the anterior wall of sphenoid sinus and was usefull for total removal of the lesion.

Origin Unknown Neck Lymphnode Metastasis, after Six Years, That Primary Site was Considered Maxillary Sinus.

A rare case of unknown origin neck metastasis is reported, in which the primary site was revealed to be the maxillary sinus six years later.A 18-year-old man was admitted to our hospital with a right cervical mass in 1993.The histological diagnosis was metastatic squamous cell carcinoma. Further examinations including the paranasal sinus did not reveal the primary lesion. After preoperative irradiation including the epipharynx, right neck dissection was performed with postoperative adjuvant chemotherapy.Four years after first admission the patient exhibited left cervical lymphadenopathy. Left neck dissection was carried out but the primary site was still unknown.Two years after the second surgery the patient exhibited right nasal obstruction and rhinorrhea, and CT scan revealed right maxillary tumor. Total maxillectomy was performed after preoperative radiation therapy and the patient has shown an uneventful good clinical course to date.In conclusion, in cases of unknown origin neck lymphnode metastasis it may be important to examine the paranasal sinus.

A Case in the Status of Pre-DIC with Intracranial Complications Caused by Paranasal Sinusitis.

A case with intracranial complications caused by paranasal sinusitis, who was also diagnosed with pre-Disseminated Intravascular Coagulation syndrome (pre-DIC). A 21-year-old male had complained of headache, high grade fever, general convulsions and consciousness disturbances. At the first examination his left superior eye lid and cheek were slightly swollen. The emergent CT revealed diffuse soft tissue density in the left ethmoidal, maxillary and sphenoidal sinuses and a low density area in the left frontal lobe. Laboratory examination of blood showed white blood cells increased, platelets decreased and fibrin degenerated products increased. These data suggested a status of pre-DIC. Moreover, analysis of cerebro-spinal fluid suggested bacterial meningitis. In order to control of sinusitis as the primary lesion, endoscopic sinus surgery was performed immediately. Not only intensive chemotherapy but also precise suction removal of the purulent secretion in the sphenoidal sinus under endoscopy were effective for control of inflammation. Nevertheless, the patients consciousness level and left hemiplegia worsened and a head-CT revealed a subdural abscess. Neurosurgical drainage was successful and the patient returned to normal. Ten weeks after surgery the patient was discharged with no functional disorder. The following examination revealed no trouble in the paranasal sinuses. This case confirmed the usefulness of endoscopic sinus surgery for the treatment of paranasal lesions and the importance of follow-up in cases of intracranial complications.