Shigehisa Hashimoto

Surgical treatment of 52 cases of auditory ossicular malformations

OBJECTIVE The aim of this study was to determine the relationship between hearing improvements and the pathological conditions of auditory ossicular malformations. METHODS Fifty-two ears (49 patients) with auditory ossicular malformations without congenital aural atresia were studied. The classification of the pathological conditions was based on surgical findings. Group 1 showed defects in the incudo-stapedial (I-S) joint, Group 2, fixation of the stapes, Group 3, fixation of the malleus and incus and Group 4, defects in the I-S joint with fixation of the stapes. Hearing improvements at the final examination were designated as successful when both of the following were satisfied. (1) Air-bone gap was reduced to 20 dB or less. (2) Postoperative hearing gain exceeded 15 dB. RESULTS Successful hearing improvements after operations were achieved in 20 ears (95%) in Group 1, 21 ears (91%) in Group 2, three ears (75%) in Group 3 and two ears (50%) in Group 4. They were observed in 88% of all cases. CONCLUSIONS Postoperative hearing improvements of auditory ossicular malformations yielded good results, particularly in Groups 1 and 2. In retrospect, the unsuccessful cases with fixation of the stapes would have been improved if stapedectomy were chosen rather than mobilization. In defects to the long process of Group 4, we wished to perform a reconstruction using the malleus attachment piston after small-fenestra stapedectomy with regard to the long-term hearing results.

A guinea pig model of adhesive otitis media and the effect of tympanostomy

OBJECTIVE The pathophysiology and prevention strategies of adhesive otitis media were investigated using two animal otitis media models induced by the inoculation of a corrosive agent into the tympanic clefts of guinea pigs. METHODS In the first experiment, KANSUI (consisting of potassium carbonate and sodium carbonate) solution was injected into the left tympanic cleft of the guinea pigs. Five groups of five animals were sacrificed at 2 weeks, and at 1, 3, 6, and 12 months after inoculation to observe the pathological changes with time. In the second experiment, a similar otitis media model was induced in 18 guinea pigs. Tympanostomy was performed at 1 and 2 weeks after induction of the otitis media to eliminate inflammatory exudate from the tympanic cleft. Three groups of six animals were sacrificed at 1, 3, and 6 months after the tympanostomy to compare the differences in pathological changes between the groups with and without tympanostomy. RESULTS In the first experiment, severe mucosal injury to the middle ear mucosa was observed at 2 weeks, and at 1 and 3 months after inoculation, and the tympanic membrane (TM) had adhered to the promontorium at 3, 6 and 12 months after inoculation. In the second experiment, TM adhesion decreased following the tympanostomy. CONCLUSION It is suggested that severe injury to the middle ear mucosa caused TM adhesion during the process of wound healing, and that tympanostomy is effective in preventing adhesive otitis media.

Cervical Spine Osteomyelitis and Epidural Abscess after Chemoradiotherapy for Hypopharyngeal Carcinoma: A Case Report

Osteomyelitis of mandible as a delayed adverse event following radiation therapy has been widely reported; however, osteomyelitis of the cervical spine has rarely been reported. In this study, we reported our experience with a case of cervical spine osteomyelitis and epidural abscess after concurrent chemoradiotherapy (CCRT) for hypopharyngeal carcinoma. The case involved a 68-year old man who underwent radical CCRT after a diagnosis of stage IVb, T4bN2cM0 posterior hypopharyngeal wall carcinoma. At 7 months after completing the initial therapy, the patient complained of severe pain in the neck and both shoulders and reduced muscular strength in the extremities. A large defect was found on the mucosa of posterior hypopharyngeal wall. On cervical magnetic resonance imaging, cervical spine osteomyelitis and an epidural abscess were observed. Because antimicrobial therapy was not effective, hyperbaric oxygen therapy was administered. Abscess reduction and improvement of the mucosal defect were observed. Because cervical spine complications after CCRT can be fatal upon worsening, adequate attention must be given.

Cervical necrotizing fasciitis treated with negative-pressure wound therapy and rehabilitation for swallowing and neck mobility: a case report

Cervical necrotizing fasciitis is characterized by rapidly progressing necrosis of the superficial layer of the cervical fascia, the loose connective tissue in the neck. We describe a case of cervical necrotizing fasciitis in a 50-year-old man with an initial diagnosis of bilateral peritonsillar abscess and upper neck cellulitis. After treatment with antibiotics he developed Lemierre Syndrome, for which he underwent surgical treatment on the fifth day of illness. Necrotizing fasciitis was diagnosed intraoperatively, and debridement and tracheotomy were performed. A total of four operations were performed, accompanied by negative-pressure wound therapy. To restore swallowing and neck movement, rehabilitation was begun soon after the first procedure. Early diagnosis of necrotizing fasciitis requires physician awareness of the possibility of this condition and careful assessment of tissues with potential necrosis. To reduce the risks of postoperative sequelae, such as swallowing disorders and limitations in neck mobility, postoperative rehabilitation should be begun before development of scar tissue or contracture.

A clinical analysis of preoperative and intraoperative surveys with parotid tumors

A retrospective review was performed on 123 patients with parotid tumor who underwent surgery at our hospital between 2010 and 2014. The age range of the subjects (75 men and 48 women) was 18‒82 years (average : 54.3). Of the 123 cases, 105 were benign and 18 were malignant. The results of preoperative computed tomography (CT), magnetic resonance imaging (MRI), fine-needle aspiration cytology (FNA), and intraoperative frozen-section (FS) were compared with the final histopathologic diagnosis. The sensitivity and specificity for detecting malignant tumors were 53.8% (10/17) and 92.4% (61/66) on CT, 58.8% (10/17) and 94.9% (94/99) on MRI, 30.8% (4/13) and 100% (81/81) on FNA, and 75.0% (12/16) and 96.9% (95/98) on FS, respectively. Our analysis showed a superiority of FS over other examinations ; however, there were 4 false negative and 3 false positive cases. In those cases, we needed to determine the extent of surgery after considering preoperative surveys and intraoperative findings of the tumor.

Successful transoral surgical closure of a hypopharyngeal pyriform sinus fistula: a case report

Abstract We describe a case of recurrent hypopharyngeal pyriform sinus fistula after an open neck surgery, which was successfully treated with transoral surgical closure. The patient was a 7-year-old boy who had previously undergone neck surgery for removal of a fistula. The fistula recurred one month later, and transoral closure was selected as a treatment. Under general anesthesia, the fistula was identified in the left pyriform sinus, and cotton balls soaked with trichloroacetic acid were inserted in the fistula opening, after which an electrocautery scalpel was used to close the fistula. At 18 months postoperatively, there has been no recurrence or complications. This is the first report to describe a transoral surgical closure of a recurrent fistula. Transoral surgical closure was successful and resulted in no complications; it thus appears to be an effective treatment option, even for patients who have previously undergone open neck surgery.

Surgical Treatment for Paranasal Mucoceles: Usefulness of Preoperative MRI and Computer-Aided Surgery

Objectives: Surgical procedures for paranasal mucoceles are associated with different levels of difficulty depending on the sites and the number of mucoceles, because the walls of mucoceles are excised and opened into the nasal cavity. We examined the usefulness of magnetic resonance imaging (MRI) in addition to computed tomography (CT) and also that of computer-aided surgery. Methods: The study involved 70 patients undergoing surgical treatment for paranasal mucoceles. Preoperative CT and MRI were carried out, and mucoceles were opened into the nasal cavity by endoscopic sinus surgery (ESS) using computer-aided surgery. Mucosal flaps were created within the nasal cavity and inserted into the mucoceles by sliding them down. Results: CT confirmed bone defect sites, and tumor differentiation was performed using MRI preoperatively. Multilocular mucoceles could be confirmed intraoperatively in 19 patients and on preoperative MRI in 18 cases (94.7%). Preoperative nasolacrimal ducts and orbital cavities were marked on the monitor by computer-aided surgery so that they could be avoided while the walls of mucoceles were excised and widely opened into the nasal cavity. There were no postoperative complications or residual mucocele, and only one patient (1.4%) showed re-closure of the opened site 6 months after the operation. Conclusions: Evaluation of the mucoceles by preoperative MRI was useful to accurately grasp the number of mucoceles and their sites. Because concomitant use of computer-aided surgery allows the mucoceles to be opened as safely and widely, it can be considered to be useful for reducing the rate of postoperative re-closure.

Procedure and Outcome in Simple Underlay Myringoplasty

Objective: To assess tympanic membrane (TM) closure rates achieved by 3 operative procedures in simple underlay myringoplasty with fibrin glue (SUM) for TM perforation. Method: A SUM was performed under local anesthesia under a microscope in patients with perforated TM defects of 50% or less. In those with defects exceeding 50%, we chose a method allowing SUM to be conducted under general anesthesia. A SUM using an endoscope was performed in cases with curved EAC. Results: A total of 158 ears were treated by SUM. There were 60 ears on which a SUM was performed using an operating microscope under local anesthesia, and complete closure was achieved in 54 (90%). Eighty-four ears were treated by a SUM under general anesthesia, and closure was achieved in 74 (88%). Endoscopy (1.9 mm in diameter) was performed in 14 ears, of which 13 (93%) attained TM closure. There were no significant differences in closure rates among the surgical procedures selected, and neither enlargement of perforation nor decreased hearing acuity occurred, as compared to the preoperative condition, even in patients suffering reperforation. Conclusion: This operative procedure is simple and minimally invasive, and provides a satisfactory perforation closure rate. The present data indicate that selection of operative procedures appropriate to various disease states may permit greater extension of surgical indications.

Management for Nonmalignant Primary Tumors of the Nasal Cavity

Objective: Assess the treatment strategy for nonmalignant primary tumors of the nasal cavity. Method: The subjects were 41 patients who underwent surgery for nonmalignant tumors of the nasal cavity during the 3 years. An endoscopic examination, contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI) were performed preoperatively, and all of the patients were treated surgically. Results: The diagnosis was papilloma in 21 cases, hemangioma in 15 cases, juvenile angiofibroma in 3 cases, and leiomyoma in 2 cases. For patients diagnosed with papilloma by endoscopy and CT, additional MRI was performed to identify the tumor base. Computer-aided surgery was used, and the tumor was endoscopically resected. Because blood flow was sufficient in cases of hemangiomas or angiofibromas, preoperative embolization was performed in 2 cases. Although external incision was anticipated in some cases, endoscopic resection of tumors was possible in all cases, and none of the patients required transfusions. Conclusion: It was possible to make the differential diagnosis between papilloma and hemangioma/angiofibroma on the basis of the preoperative endoscopic and CT findings. Safe and reliable resection was possible by combined use of MRI and computer-aided surgery for the papillomas, and use of embolization for the hemangiomas and angiofibromas.

S219 – Japanese Otosclerosis Patient with Otospongiotic Lesions

Objectives Although it has been reported that the incidence of otosclerosis is much lower among Japanese patients and clinically the disease shows a reduced activity level, otosclerotic foci are sometimes detected in recent years. However, about the clinical significance, it is not still unclear. This study investigated the incidence of otosclerosis in Japanese patients with otosclerotic foci around the otic capsule, their audiometric correlation and surgical outcome. Methods We evaluated 59 patients (86 ears) with confirmed otosclerosis (at least one ear underwent surgery) in our hospital between 2001 and 2006. All patients underwent hearing and CT examination on the same day and hearing examination were repeated every 6 months regardless of whether the patient underwent surgery or observation only. Results Otosclerotic foci around the otic capsule were observed in 30.2% of the all ears in the Japanese otosclerosis. There was a correlation between the presence of otosclerotic foci and air-bone gap (p<0.05). In the surgical group, there was no significant difference between the patients with and without the presence of otosclerotic foci for the hearing improvements after stapes surgery. In the no-surgical groups, there was significant worsening of the hearing level in patients with otosclerotic foci in comparison to that of those without otosclerotic foci (p<0.01). Conclusions This incidence of Japanese otosclerosis patient with otosclerotic foci is not lower than those of Caucasians. Surgical outcome was not affecting by otosclerotic foci. It is concluded that CT examination is important for predicting the hearing level of patients.