Masanobu Shinogami

Auditory Nerve Disease of Both Ears Revealed by Auditory Brainstem Responses, Electrocochleography and Otoacoustic Emissions

We report on two patients who showed absence of auditory brainstem response (ABR) but broad compound action potentials on electrocochleograms and almost normal otoacoustic emissions, together with absence of caloric response and preservation of per rotatory nystagmus for both ears. Patient 1, a 53-year-old woman, had noted auditory and vestibular problems since the age of 15 years, and Patient 2, a 68-year-old woman, had noted problems of the same age of 30 years. They could hear words and understand sentences if spoken slowly, but they could not discriminate monosyllables very well. Their auditory examinations disclosed mild threshold elevation in pure-tone audiometry and markedly poor scores in speech audiometry and good scores in auditory comprehension test. They were diagnosed as having auditory nerve disease of unknown cause.

Factors Associated with Poor Outcome in Children with Acute Otitis Media

Objective --To identify factors determining poor outcome in children with acute otitis media (AOM). Material and Methods --We considered the following factors in children with AOM: age; gender; the presence of group nursing; the presence of siblings; the duration of breastfeeding; and the type of bacteria isolated from the middle ear fluid (MEF) or nasopharynx. The 73 pediatric patients studied included 61 examined in outpatient clinics and 12 seen at a childrens home. Results --Of the 61 children examined in outpatient clinics, 32 (52%) had persistent MEF (fluid accumulation in the middle ear persisting for up to 1 month after treatment); 14 (23%) had early recurrence of AOM (within 1 month following an initial improvement); and 14 (23%) developed recurrent AOM (> 3 recurrences during 6 months of follow-up). Using univariate and multivariate analyses, age < 2 years was found to be significantly related to the development of recurrent AOM and an absence of group nursing was found to be significantly related to the development of early recurrence. Persistent MEF was significantly related to the development of recurrent AOM. There was no difference between bacterial species isolated from the MEF or nasopharynx in terms of clinical outcome. Conclusion --These findings indicate that particularly close long-term follow-up is necessary for children aged < 2 years and children with a middle ear effusion that persists for up to 1 month after treatment.

Role of respiratory viruses in children with acute otitis media

OBJECTIVE The role of viral infection in acute otitis media (AOM) has not been fully elucidated. We determined the presence of various respiratory viruses in middle ear fluid (MEF) specimens from children with AOM in order to determine whether viral infection or combined effects of viral and bacterial infection enhance or prolong the inflammation in the middle ear, thus worsening clinical outcome. METHODS Multiplex nested reverse transcription-polymerase chain reactions was carried out to detect influenza A and B viruses, respiratory syncytial virus (RSV) types A and B, parainfluenza virus types 1, 2, and 3; rhinovirus; and adenovirus in 93 MEF specimens from 79 children with AOM. And we examined whether viral infection with or without an identifiable bacterial infection affect clinical outcomes in AOM. We considered persistent MEF (fluid accumulation in the middle ear persisting up to 1 month after treatment), early recurrence of AOM (within 1 month after initial improvement), and recurrent AOM (more than three recurrences during 6 months of follow up) as indicators for evaluating clinical outcomes. RESULTS One or more respiratory viruses were detected in 39 specimens (42%); a total of 42 viral infections identified (three specimens were infected by two viruses). Of the 42 infections, RSV type A was detected in 29, adenovirus in eight, rhinovirus in three, and influenza virus in two. RSV accounted for 73% of viral detections. In children younger than 2 years, RSV infection combined with Streptococcus pneumoniae or Hemophilus influenzae infection carried a higher risk for persistent middle ear effusion than infection with RSV infection alone or those bacterial infection alone. CONCLUSIONS Accordingly, vaccination of young children against RSV as well as S. pneumoniae and H. influenzae is important in improving the prognosis in AOM.

Induction of KGF, Basic FGF, and TGFa mRNA Expression During Healing of Experimental TM Perforations

KGF (KGF), synthesized and secreted exclusively by stromal cells in epithelialized organs, specifically promotes proliferation of cells of epithelial origin, including keratinocytes. A related peptide, basic fibroblast growth factor (bFGF), has mitogenic properties for fibroblasts and endothelial cells. KGF expression is stimulated markedly in the skin during wound healing. To investigate the physiologic action of KGF in the healing of TM (TM) perforations, we examined KGF and KGF receptor (KGFR) mRNA transcript levels as well as those of bFGF and transforming growth factor-alpha (TGFalpha) in normal and wounded rat TM at varying intervals, using a semiquantitative reverse transcription-polymerase chain reaction (RT-PCR). We found KGF and TGFalpha mRNA expression to be induced rapidly, peaking 3 days after wounding and then declining. Expression of bFGF was induced gradually and remained increased until 7 days. In contrast, we found KGFR to be expressed in normal TM, remaining unchanged during TM repair. These results indicate that KGF and TGFalpha may mediate migration and proliferation of epithelial cells of the outer layer in the early stage of TM repair while bFGF may mediate the connective tissue reaction in the middle layer in a subsequent stage.

Keratinocyte Growth Factor and Receptor mRNA Expression in Cholesteatoma of the Middle Ear

Keratinocyte growth factor (KGF) is synthesized and secreted exclusively by stromal cells in epithelialized organs, and specifically promotes proliferation of cells of epithelial origin, including keratinocytes. Cholesteatoma is a proliferative form of keratinocyte dysregulation with aggressive growth that often leads to destruction of adjacent bone. We examined the expression of KGF, closely related peptides and their receptors in the development of cholesteatoma by comparing cholesteatoma with normal ear skin using the reverse transcription-polymerase chain reaction (RT-PCR) followed by Southern blot analysis. All surgical specimens of cholesteatoma and most normal ear skin samples expressed detectable levels of KGF and KGF receptor (KGFR). Semiquantitative RT-PCR using beta-actin mRNA as an internal standard revealed significantly higher expression of KGF mRNA in cholesteatoma than in normal skin, while no significant difference in KGFR mRNA expression was noted between cholesteatoma tissue and normal skin. These results suggest that excessive KGF synthesis may contribute to the hyperproliferative state in cholesteatoma.

Prognosis of Tinnitus After Acoustic Neuroma Surgery—Surgical Management of Postoperative Tinnitus

OBJECTIVE Tinnitus is a bothersome symptom for patients with acoustic neuroma. We studied the possibility of surgical control of postoperative tinnitus associated with acoustic neuroma. METHODS Postoperative changes and prognosis of tinnitus were studied in 367 patients treated surgically via a lateral suboccipital retrosigmoid approach. RESULTS Postoperative prognosis of tinnitus was as follows: resolved in 20%, improved in 22%, unchanged in 35%, changed in 10%, and worsened in 14% of 290 patients who had preoperative tinnitus, and no tinnitus in 78% and appeared in 22% of 77 patients without preoperative tinnitus. Prognosis of postoperative tinnitus was influenced by age, tumor size, preoperative hearing acuity, types of preoperative hearing disturbance, and conditions of the cochlear nerve after tumor resection. Worse prognosis of postoperative tinnitus in the preoperative tinnitus group was found in younger patients, smaller tumor size, better preoperative hearing function, and normal or retrocochlear type of hearing disturbance. Regarding the conditions of the cochlear nerve after tumor resection, prognosis of tinnitus was significantly worse in the group of anatomically preserved cochlear nerve without useful hearing than in the group of cut cochlear nerve. CONCLUSIONS Deciding whether to cut the cochlear nerve during acoustic neuroma surgery by referring to a flowchart, we proposed in cases where hearing preservation is not intended or judged less possible contributes to controlling postoperative tinnitus. However, regardless of whether the cochlear nerve was cut intraoperatively, tinnitus remained unchanged in 37% of patients, suggesting that their tinnitus originates in the brainstem or post-brainstem pathways before surgery, and it is considered difficult to control postoperative tinnitus in these cases.

Stroboscopic Observation of the Larynx After Radiation in Patients with T1 Glottic Carcinoma

We studied laryngeal video stroboscopy (LVS) system for evaluation of patients with glottic carcinoma (T1N0M0) before and after radiotherapy. There were 10 patients with T1 glottic squamous cell carcinoma (9 men and 1 woman) who received radiotherapy at the Hitachi General Hospital. We performed LVS before and after radiotherapy. The presence or absence of mucosal waves (MW) was particularly noted. No MW were present before radiotherapy but at 1-6 months after, MW gradually appeared. One year after radiotherapy all patients showed MW on LVS. In patients with glottic carcinoma MW recovered after radiation therapy. LVS may be useful for the clinical follow-up of post-radiation patients for early detection of recurrence of glottic carcinoma.

Bilateral Isolated Metastases of Malignant Melanoma to the Cerebellopontine Angle

M a l i g n a n t melanoma can spread throughout the body, including the central nervous system (CNS). Intracranial metastases are commonly diffuse and multiple. Metastatic melanomas to the cerebellopontine angle (CPA) are usually found at autopsy in conjunction with widely disseminated CNS disease. 1-4 Isolated metastasis to the CPA or the internal auditory canal (IAC) is exceedingly rare. To our knowledge, only five cases of metastatic melanoma limited to the CPA have been reported. 5-7 We here report a case of bilateral isolated metastases of malignant melanoma to the CPA and discuss the clinical presentation, pathophysiologic characteristics, differential diagnosis, and management of metastatic melanoma of the CPA.

Multiplex Nested Reverse Transcription-Polymerase Chain Reaction for Respiratory Viruses in Acute Otitis Media

Because respiratory viruses play an important role in the causation and pathogenesis of acute otitis media (AOM), determining which virus has infected a child is important with respect to vaccines and antiviral drugs. In some instances, this information might be used to prevent the occurrence of AOM. We used a rapid, economical, and sensitive diagnostic system involving a multiplex nested reverse transcription–polymerase chain reaction (RT-PCR) assay to detect various respiratory viruses in clinical specimens of middle ear fluid (MEF) from children with AOM in our hospital. Multiplex RT-PCR was completed on 40 MEF samples from 28 infants and children less than 6 years old with AOM. Viral RNA was detected in 17 MEF samples (43%). Respiratory syncytial virus type A was present in 12 samples, adenovirus in 3, rhinovirus in 2, and influenza A (H3N2) in 1. The multiplex RT-PCR assay is recommended to clinical laboratories that are considering adoption of a molecular technique for viral diagnosis.

Bent (head-down) posture and aberrant common carotid arteries of the neck: another new risk factor for stroke?

ver, questioning its reproducibility and validity as predictive tool.3 They argue that assessment with Muller’s maneuver can identify palatal obstruction preoperatively and that elimination of palatal obstruction will increase the airflow postoperatively. Eliminating palatal obstruction may result in increasing negative pressures with subsequent obstruction at a lower level. We fully agree that Muller’s maneuver is not a very valuable test to predict the obstruction site. Remodelling the upper airway does have consequences for its dynamics and airflow patterns, which may result in obstruction at tongue base level rather than at hypopharyngeal level. Changing the architecture of the upper airway might be an additional reason why we cannot predict surgical outcomes preoperatively. Anatomical staging has a large cost-benefit when compared to sleep endoscopy, but we believe that combining the two tests may help improving surgical outcomes even more, since both policies lead to fewer UPPP failures. In case the outcome of both screening tests is equal, there is little reason for concern. In case of conflicting outcome, however, it remains unclear which of the screening modalities is superior. In this respect, more research is mandatory.