Masafumi Ohki

Idiopathic tinnitus concomitant with eye closure.

Objective To describe 2 patients presenting with idiopathic tinnitus concomitant with eye closure. Study Design Clinical capsule report. Setting University hospital. Patients Two patients presented with intermittent tinnitus synchronous with eye closing or blinking. Otoscopic examination revealed inward movement of tympanic membranes concomitantly with eye blinking or eye closure in 1 patient. Neither patient had facial nerve disease or myoclonus. Interventions Compliance in impedance audiometry was recorded. Results Compliance in impedance audiometry was reduced during eye blinking and eye closure in both cases. The tinnitus was attributed to muscular tinnitus via stapedial muscle contraction during eye closure. Conclusion These are the rare 2 reported patients presenting with idiopathic muscular tinnitus concomitant with eye closure. The reductive change of compliance in impedance audiometry during tinnitus coincident with eye closure is a feature of this form of tinnitus. We suggest evaluation of compliance change in impedance audiometry to be a key examination in patients with stapedial muscular tinnitus concomitant with eye closure.

Temporal bone histopathology case of the month. First branchial cleft anomaly with an orifice in the bony external auditory canal accompanied by contralateral middle ear cholesteatoma.

First branchial cleft anomalies are rare. These anomalies are caused by incomplete fusion of the first cleft between the first and second branchial arches and occur at a frequency of approximately 1% to 10% among all branchial anomalies (1,2). The external auditory canal is derived from the first branchial cleft, and it is commonly accompanied by an orifice on the floor of the external auditory canal, either at the level of the bony-cartilaginous junction or in the cartilaginous portion (2). A first branchial cleft malformation sometimes accompanies an anomaly of the external ear canal or middle ear and cholesteatoma (1Y4). Here, we report a rare case of a first branchial cleft sinus orifice in the bony external auditory canal accompanied by contralateral middle ear cholesteatoma containing an aberrant bony structure. A 63-year-old woman presented with a right upper neck mass that developed rapidly within a few days. Although she reported episodes of swelling and purulent discharge from the area during her youth, she had been symptom-free for 45 years. There was no visible orifice on her neck, but scarring was noted. Her right tympanic membrane was partly atrophic without perforation, and there was an orifice in the bony external canal (Fig. 1A). Computed tomography (CT) scan showed that the orifice passed vertically through the temporal bone toward the upper neck (Fig. 1, B and C). Magnetic resonance imaging (MRI) revealed a cyst on the right side extending from the deep portion of the parotid gland to the parapharyngeal space (Fig. 1, DYF). The left tympanic membrane was perforated and accompanied by a cholesteatoma visible at the anteroinferior quadrant behind the annulus (Fig. 2, AYC). The patient was diagnosed with a right first branchial cleft sinus and a left middle ear cholesteatoma. After 6 months, she underwent excision of the right first branchial cleft sinus by a submandibular approach. The right submandibular gland was resected to visualize the parapharyngeal area. The first branchial cleft sinus was found to be connected to the bony external ear canal by a cartilaginous duct, whichwas ligated at the border between the bony canal and cartilaginous duct, and the sinus was resected. The duct passed medially to the facial nerve but did not cross it, and there was no indication of postoperative facial nerve palsy. Histologically, the sinus was composed of a lumen with stratified squamous epithelium connected to a cartilaginous tract (Fig. 3). One year after excision of the right first branchial cleft sinus, the left middle ear cholesteatoma was removed, and type 1 tympanoplastywas performed. All 3 ossicles were intact with good mobility. Histologically, the cholesteatoma contained bony tissue (Fig. 2D). There has been no recurrence as of 2 years after removal of the first branchial cleft sinus. The anterior and medial walls of the tympanic cavity are formed by the first branchial arch, whereas the floor of the tympanic cavity is formed by the second branchial arch (5). The borderline between the first and second branchial arches is a possible site of residual tissue of the first branchial cleft. Therefore, in our case, the cholesteatoma containing the bony structure was possibly an aberrant structure related to an anomaly of the contralateral first branchial cleft.

An isolated vestibulocochlear symptom preceding brainstem infarction due to basilar artery occlusion.

Objective To describe unilateral hearing loss preceding brainstem infarction due to basilar artery occlusion. Study Design Clinical capsule report. Setting University hospital. Patient A 67-year-old woman presented with unilateral acute hearing loss with dizziness as a sole prodromal manifestation of basilar artery occlusion for 2 weeks before the appearance of motor and oculomotor deficits. Intervention Otologic examinations and magnetic resonance imaging (MRI) were performed. Results A pure-tone audiogram showed unilateral profound sensorineural hearing loss preceding brainstem occlusion. Diffusion-weighted MR image demonstrated acute infarction around the paramedian area of the upper and middle pons, although T2-weighted MR image showed a normal brain image except for occlusion of the basilar artery. Conclusion Acute unilateral hearing loss could be a prodrome of basilar artery occlusion. Clinicians must consider this possibility, especially in patients at high risk of brainstem infarction.

Oral frostbite due to dry ice.

Objectives: Dry ice is a commercially available cryogen that is used worldwide. It may cause frostbite if misused. However, frostbite of the oral cavity due to dry ice has not been previously reported. Here, we describe the first case of dry ice–induced frostbite of the oral cavity. Methods: We present a case of oral frostbite due to dry ice and subsequent swelling of the submandibular area and lower lip. We discuss the clinical features of oral frostbite due to volatile substance abuse. Results: Oral frostbite not only may result in the impairment of the affected mucosae directly, but also may adversely affect the tissues in the vicinity of the oral cavity floor indirectly. Oral frostbite may cause edema of the upper airway tract. In case of severe pharyngolaryngeal edema, either tracheal intubation or tracheostomy is necessary. Steroids and antibiotics may be effective in preventing the development of pharyngolaryngeal edema. Conclusions: It is important to bear in mind that volatile substance abuse may possibly induce unusual events. In particular, special attention should be paid to delayed unusual events.

Organised haematoma of the maxillary sinus: pathophysiological differences suggesting a new aetiological hypothesis

BACKGROUND AND OBJECTIVES Organised haematomas of the maxillary sinus are rare, non-neoplastic, haemorrhagic lesions which can extend into the nasal cavity and/or the other paranasal sinuses. This study aimed to investigate the pathology of maxillary sinus organised haematoma, and also proposes a new aetiological hypothesis based on the observed pathology. METHODS Biopsies, computed tomography, magnetic resonance imaging and post-surgical histopathological examination of resected specimens were carried out. CONCLUSION Distinct pathological differences were observed between the basal and peripheral portions of organised haematomas. We propose that an organised haematoma originates from the exudation of blood components between vascular endothelial cells. As a result, the basal portion consists of aggregated, dilated vessels around the natural ostium of the maxillary sinus. In addition, pseudovessels, without endothelial cells, arise from endocapillary vessels within the haematoma. Exudation of additional blood components from the pseudovessels advances the growth of the organised haematoma.

Surgical results of transcanal endoscopic ear surgery in chronic otitis media.

Learning Objectives: Patulous eustachian tube (PET) can have a significant negative impact on a patient’s quality of life. Several methods of surgical management can be an option to treat PET, and our objective is to evaluate the safety and efficacy of autologous cartilage injection in patients with PET. Thirty-three ears of twenty-five patientswith chronic PET refractory to conservative treatment were enrolled to this study. Autologous tragal cartilage was harvested, and chopped into fine pieces to allow its injection using a 1cc Bruening syringe. Endoscopic cartilage injection was performed submucosally into the anterior (0.5 mL) and posterior aspects (0.5 mL) of the nasopharyngeal ET under local anesthesia in an operating room. Patients were evaluated postoperatively by nasal endoscopy and by interview to document symptoms. Successful treatmentwas defined as complete relief or significant improvement plus satisfaction with treatment. The only complication that occurred was temporary otitismediawith effusion in one ear. Inferior turbinate reduction was performed in three ears with accompanying nasal septal deviation or turbinate hypertrophy to allow better nasopharyngeal ET visualization. After autologous cartilage injection, the successful treatment rate, as determined by subjective autophony symptoms, was 69.7% (23/33). The average follow-up period was 25.2 months. Autologous cartilage injection is a minimally invasive technique that has been used by the authors to successfully treat patulous eustachian tube. The described procedure was found to provide a good overall success rate without long-term complications.

Pharyngolaryngeal paralysis in a patient with pharyngeal tuberculosis

Pharyngeal tuberculosis is a rare disease, and its commonly reported symptoms include sore throat, dysphagia, and throat discomfort. The dysphagia in pharyngeal tuberculosis cases is not due to pharyngolaryngeal paralysis but due to odynophagia. Herein, we describe the first case of dysphagia caused by pharyngolaryngeal paralysis secondary to pharyngeal tuberculosis. An irregular mass at the right nasopharynx was detected in a 57-year-old female patient, along with dysphagia and hoarseness. She had poor right soft palate elevation, inadequate right velopharyngeal closure, poor constrictor pharyngus muscle contraction, and an immobilized right vocal cord, which collectively indicate right pharyngolaryngeal paralysis. Pathological examination and culture testing revealed pharyngeal tuberculosis. She was diagnosed with pharyngolaryngeal paralysis secondary to pharyngeal tuberculosis. The pharyngolaryngeal paralysis resolved after beginning anti-tuberculous treatment. Right pharyngolaryngeal paralysis was attributed to glossopharyngeal and vagus nerve impairment in the parapharyngeal space. Prior reports indicate that peripheral nerve paralysis, including recurrent laryngeal nerve paralysis caused by tuberculous lymphadenitis, often recovers after anti-tuberculous treatment. Pharyngeal tuberculosis rarely causes dysphagia and hoarseness attributable to pharyngolaryngeal paralysis. The neuropathy may recover after anti-tuberculous treatment. Pharyngeal tuberculosis is a new potential differential diagnosis in pharyngolaryngeal paralysis.

Thrombophlebitis of the head and neck caused by eosinophilic otitis media.

Objective To describe the clinical course and treatment of a patient presenting with thrombophlebitis of the head and the neck with eosinophilic otitis media (EOM). Patient The patient was a 32-year-old woman with bronchial asthma and chronic sinusitis. She was treated for EOM, which presented as intractable otitis media with viscous effusion. Subsequently, she experienced sudden onset of nausea and headache. No signs of improvement were observed after the intravenous administration of several antibiotics. Magnetic resonance imaging (MRI) revealed right thrombophlebitis extending from the sigmoid sinus to the jugular vein. Interventions Systemic administration of adrenocortical steroid hormone after intravenous antibiotic therapy. Main Outcome Measures Radiologic features and patient symptoms. Results Intravenous antibiotic therapy was ineffective, but the patient’s symptoms were relieved less than 1 day after the initiation of prednisolone treatment (30 mg/d for 5 d). MRI performed 3 days after treatment revealed that thrombophlebitis of the head and neck had disappeared. Conclusion Adrenocortical steroid hormone therapy may be an effective treatment for thrombophlebitis with EOM. Chemoattractants activated by EOM might be associated with the pathogenesis of thrombophlebitis of the head and neck.

Bilateral objective tinnitus in an infant with tuberous sclerosis.

This is the first report of objective tinnitus presenting as audible spontaneous otoacoustic emission in a patient with tuberous sclerosis. The tinnitus was loud, continuous, and high pitched: 7757.8 and 6257.8 Hz. The auditory system may be dysfunctional in patients with tuberous sclerosis. Possible causes of tinnitus in these patients are abnormal myelination and dysfunctional axons and neurons associated with tuberous sclerosis. A disturbance of the outer hair cells or the MOC efferent fibers innervating the outer hair cells is considered to be the source of the loud spontaneous otoacoustic emission.

Dysphagia due to isoniazid therapy for tuberculosis in a patient with Lewy body dementia.

Dementia with Lewy bodies (DLB) potentially causes dysphagia; however, the features and underlying mechanism causing dysphagia have still not been clarified. We are the first to report a case of dysphagia resulting from isoniazid therapy for tuberculosis in a DLB patient. A 74-year-old woman with DLB developed dysphagia during treatment for tuberculous pleurisy. Oral videoendoscopic and videofluorographic swallowing examinations showed oropharyngeal dysphagia. The increased administration of levodopa successfully ameliorated dysphagia. Therefore, dysphagia was ascribed to diminished levodopa efficacy due to interaction with isoniazid. Thus, DLB patients receiving anti-tuberculous therapy should be closely examined for potential changes in swallowing and Parkinsonism.