Takahiro Ichihara

Evaluating the effects of testing period on pollinosis symptoms using an allergen challenge chamber

BACKGROUND We previously built a pollen challenge test unit (allergen challenge chamber: ACC) to collect objective data about Japanese cedar pollinosis. In this study, we investigated adequate conditions for pollen challenge using the ACC. METHODS The study consisted of two parts. The first part was conducted in November, which is not in pollen season. Subjects were exposed to Japanese cedar pollen at a concentration of 50,000 grains/m3 in the chamber for 120 min each day over the course of three consecutive days. The second part was conducted in April, which is just after pollen season. Subjects were exposed to Japanese cedar pollen at the same concentration (50,000 grains/m3) in the chamber for 90 min on a single day. Subjects recorded nasal and ocular symptoms before challenge and every 15 min after challenge initiation. The minimum cross-sectional area in the nasal cavity was measured using acoustic rhinometry before and after challenge as an indicator of nasal obstruction. Inflammatory markers in nasal lavage fluid and serum were also measured before and after challenge. RESULTS Nasal and ocular symptoms were significantly exacerbated after challenge on all days of the single and 3-consecutive-day challenge tests, particularly on the third day of the consecutive challenge test. Nasal and ocular symptoms were also quickly induced with challenge immediately after the end of pollen season. No significant changes in inflammatory markers were seen. CONCLUSIONS Care is needed with regard to pollen challenge conditions in the ACC, including timing of the challenge, to induce pollinosis symptoms that accurately reflect chronic inflammation.

Preliminary study of a challenge test to the patients with Japanese cedar pollinosis using an environmental exposure unit

OBJECTIVE Although clinical studies on pollinosis have been performed employing placebo-controlled double-blind comparative and field techniques, accurate evaluation is difficult because the scattering pollen count and climatic conditions vary between years and regions, leading to a bias in the results. Thus, we prepared a pollen challenge test unit (allergen challenge chamber: ACC) which facilitates quantitative pollen challenge at any time, and, so, the acquisition of objective data. METHODS The control of constant conditions and maintenance of specified pollen concentrations in ACC were investigated. In addition, the pollen distribution in ACC was measured while maintaining the level at 10,000 counts/m(3). The pollen levels were measured employing the aspiration and Durham methods, and the measured values were compared. Furthermore, whether symptoms are adequately induced in the chamber during the non-cedar pollen-scattering season was investigated in 14 volunteers with cedar pollinosis. RESULTS When the pollen level in ACC was set at 6000 counts/m(3) or higher, the rate of variation was +/-15%, within the adjustable range, and that of the pollen distribution in the chamber was within +/-20%. When the volunteers with cedar pollinosis were exposed to cedar pollen in ACC, pollinosis symptoms were induced, and challenge for 2 consecutive days significantly induced symptoms. CONCLUSIONS The temporal and spatial variations of the pollen level in ACC were small, facilitating stable pollen challenge, and pollinosis symptoms were induced in the volunteers with cedar pollinosis. The challenge chamber may be useful to judge the effects of therapy against pollinosis.

A more appropriate clinical classification of benign parotid tumors: investigation of 425 cases

Abstract Conclusions: It is appropriate to clinically classify benign parotid tumors into three groups, i.e. superficial tumors, deep tumors, and lower pole tumors. Objective: It is important to classify benign parotid tumors based on location when deciding the surgical strategy and conducting clinical research. In this study, we examined a classification of benign parotid tumors that was useful for clinical practice. Methods: We studied 425 patients with benign parotid tumors who underwent surgery at our hospital. Their age, gender, tumor histopathology, maximum tumor diameter, postoperative facial nerve paresis, operating time, and blood loss were investigated after classifying the tumors as superficial tumors, deep tumors, or lower pole tumors. We also investigated the same parameters after dividing the lower pole tumors into superficial and deep types. Results: Lower pole tumors had distinct characteristics from superficial and deep tumors. The incidence of facial nerve paresis was significantly higher and the operating time was significantly longer for deep tumors than for either superficial or lower pole tumors, while there were no significant differences between superficial and lower pole tumors. In addition, there were no significant differences in any of the parameters between the superficial and deep types of lower pole tumor.

Kimura's disease of the epiglottis: resection by a lateral pharyngotomy approach.

Kimura’s disease is a chronic non-neoplastic entity first described by Kimura et al in 1948. It predominantly occurs in Asian males during the second and third decades of life. The major physical manifestation is slowly enlarging subcutaneous masses often found in the head and neck, especially in the salivary glands, usually in association with peripheral blood and tissue eosinophilia and a markedly increased serum IgE concentration. Although many cases have been reported, development in the larynx is very rare, possibly leading to difficulties in diagnosis. We report a case of Kimura’s disease presenting as an epiglottic mass, which was resected by a lateral pharyngotomy approach (LPA). A 52-year-old female presented to our department with a 10-month history of sensation of a foreign body in her pharynx. ENT examination revealed a 30-mm, well-defined, submucosal epiglottic mass (Fig 1). No enlarged lymph nodes were palpable in cervical regions, and there were no lesions in the salivary glands. MRI showed a diffuse enlargement of the epiglottis with a low-intensity signal in both T1and T2-weighted images. CT also showed an epiglottic mass with slight enhancement (Fig 2). These findings suggested a tumorous lesion in the epiglottis, such as malignant lymphoma. The white blood cell (WBC) count was 6800/mm, with 12.5 percent eosinophils. We did not measure serum IgE concentration. During direct laryngoscopy with the patient under general anesthesia, we detected a submucosal tumor covered with a normal mucous membrane in the epiglottis, making the laryngeal space at the epiglottic level very narrow. We incised the mucous membrane and took a biopsy sample from the mass. These findings suggested low-grade malignant lymphoma. The specimen was too small to make a definite diagnosis pathologically, so we performed an LPA to obtain a larger sample. The mass was found to be closely adhered to the epiglottis, so subtotal removal was performed. The mass was firm, reddish-white, and measured 4 3 3 cm. Histopathologically, multiple hyperplastic

The midline electroneurography method for facial palsy reflects total nerve degeneration.

Abstract Conclusion: The midline electroneurography (ENoG) method might reflect total facial nerve degeneration. Objective: We compared ENoG values in patients with facial palsy using two different methods, the midline method and five electroneurogram recordings, to reveal whether the ENoG value obtained with the midline method reflects total facial nerve degeneration. Methods: Forty patients with facial palsy were enrolled. Compound muscle action potentials (CMAPs) were recorded using the midline method, in which the anode was placed on the mental protuberance and the cathode was placed on the philtrum. Additionally, five electroneurogram recordings were obtained by placing the anode on the skin of the parietal region and five cathodes on the skin over five facial muscles (frontalis, orbicularis oculi, nasalis, orbicularis oris, and depressor anguli oris muscles). ENoG values recorded using the two methods were compared. Results: The ENoG values of the five facial muscles did not differ from those obtained using the midline method. The total ENoG value calculated by summing five CMAPs from five facial muscles, which is considered to reflect total facial nerve degeneration, was not significantly different from that using midline methods; moreover, a strong positive correlation coefficient (r = 0.87) was found between them.

Varicella-zoster virus–specific cell-mediated immunity in Ramsay Hunt syndrome

The etiology of Ramsay Hunt syndrome (Hunt syndrome) is reactivation of latent varicella‐zoster virus (VZV) in the geniculate ganglion of the facial nerve, leading to neuritis. Although the mechanism of the VZV reactivation is unclear, one possibility is that the reactivation involves a low level of VZV‐specific cell‐mediated immunity (CMI). The aim of this study was to clarify the characteristics of the VZV‐specific CMI in Hunt syndrome compared to that in Bells palsy, and to obtain clues to its role in the development of Hunt syndrome.

Metastatic breast carcinoma to bilateral internal auditory canals.

Metastatic tumors in the cerebellopontine angle are rare. Origins of these tumors include breast cancer, lung cancer, colon cancer, and malignant melanoma (1). Unilateral internal auditory canal (IAC) metastasis mimics sporadic vestibular schwannoma (2Y4). In contrast, metastatic tumors in the bilateral IACs, which are extremely rare, mimic neurofibromatosis type 2 (NF-2) (5). Our patient was a 65-year-old woman with a history of a mastectomy for left papillotubular breast carcinoma at the age of 48 years. At 63 years of age, she developed left axillary lymph node metastases treated with chemotherapy. One year later, multiple metastases appeared in the first lumbar vertebra and pelvic lymph nodes, and the patient underwent additional chemotherapy and conventional radiation therapy (2 Gy per day; total, 50 Gy). During the period of the radiation therapy, the patient experienced sudden bilateral deafness and concurrent nausea. Audiometry revealed profound bilateral sensorineural hearing loss, and no reliable waves were observed bilaterally in auditory brainstem response tests. Brain computed tomographic scans showed no abnormal lesions; however, magnetic resonance imaging (MRI) revealed gadolinium-enhanced masses in the bilateral IACs (13.4 6.2 mm in the right and 11.3 7.1 mm in the left; Fig. 1). Within 40 days after the onset of sudden deafness, bilateral complete facial palsy (HouseYBrackmann grade VI) developed with a balance disorder. Although no spontaneous nystagmus was observed, the patient never walked independently. A follow-up MRI scan taken 1 month after the first showed rapid tumor growth bilaterally (18.7 11.3 mm in the right and 16.1 10.8 mm in the left; Fig. 2A) and revealed another lesion in the left hemisphere of the cerebellum (Fig. 2B). The patient was diagnosed with metastatic breast carcinoma to the IACs bilaterally with meningeal carcinomatosis. Stereotactic radiosurgery was performed on the bilateral IAC tumors (18 Gy each) and the cerebellar tumor (20 Gy); however, she died 50 days after the follow-up MRI because of respiratory insufficiency. The differentiation of metastatic tumors in bilateral IACs from NF-2 is important. Early interval MRI scans are useful to evaluate the speed of growth in patients with possible metastases to the IACs. When we encounter patients with tumors in the bilateral IACs who have no cancer histories, positron emission tomography or positron emission tomographyYcomputed tomography is desirable in screening for any type of cancer in the whole body in addition to repeated MRI. Address correspondence and reprint requests to Shin-Ichi Haginomori, M.D., Department of Otolaryngology, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; E-mail: hagi@poh. osaka-med.ac.jp The authors disclose no conflicts of interest. FIG. 1. First MRI (axial gadolinium-enhancedT1-weighted).White arrows indicate masses in bilateral auditory canals. Otology & Neurotology 33:e35Ye36 2012, Otology & Neurotology, Inc.

A new electroneurography as a prognostic tool for marginal mandibular nerve paralysis after parotid gland surgery: A preliminary evaluation

OBJECTIVE Marginal mandibular nerve paralysis is the most frequent complication of benign parotid tumor surgery and results in cosmetic deformity. The purpose of this study was to develop a new electroneurography method for marginal mandibular nerve paralysis using electroneurography (ENoG) and judge its usefulness for clinical practice. METHODS Twenty-seven patients who underwent surgery for benign parotid tumor were enrolled. We proposed and use the mandibular angle method, in which the recording electrode was placed on the skin above the depressor anguli oris muscle while the reference electrode was placed on the skin of the parietal region, and percutaneous electrical stimulation was applied to enclose the mandibular angle that could measure the function of the marginal mandibular nerve solely. Preoperative and postoperative ENoG values were compared in paralytic and non-paralytic patients. RESULTS The mean postoperative ENoG value (35.0%) was lower than the preoperative value (90.5%) in paralytic patients, whereas no difference was observed between preoperative (79.3%) and postoperative (69.5%) ENoG values in non-paralytic patients. CONCLUSION A new ENoG method (mandibular angle method) was thought to reflect marginal mandibular nerve injury and might be useful for determining the likelihood of paralysis.

Postoperative Middle Ear Aeration and Hearing Results after Canal Wall Down Tympanoplasty with Soft-Wall Reconstruction

Objectives: (1) Estimate the degree of postoperative aeration in the middle ear after canal wall down tympanoplasty with soft-wall reconstruction (CWD tympanoplasty with SWR) for cholesteatoma. (2) Characterize the relationship between postoperative middle ear aeration and hearing outcome. (3) Propose an ideal state of middle ear aeration in order to obtain satisfactory hearing outcome after CWD tympanoplasty with SWR. Methods: This retrospective study was conducted in our tertiary referral hospital between 2001 and 2013. Seventy-eight ears with cholesteatoma treated surgically at our hospital by planned two-stage CWD tympanoplasty and SWR were included. Postoperative middle ear aeration was scored one year after second-stage surgery by computed tomography (CT). The patients were divided into 4 bins according to postoperative audiometric air-bone (A-B) gaps: 0-10, 11-20, 21-30, and >30 dB. Results: Postoperative middle ear aeration was significantly greater in the smaller A-B gap bins (0-10 and 11-20 dB) compared with the larger A-B gap bins (21-30 and >30 dB). In contrast to the larger A-B gap bins, those with smaller A-B gaps showed reaeration of the antrum and mastoid cavity. Conclusions: Promoting postoperative aeration of the entire middle ear is necessary to achieve better hearing outcome in patients undergoing CWD tympanoplasty with SWR for cholesteatoma. The ventilation tube insertion and placement of the large silicone sheet from the protympanum to the mastoid cavity in the first-stage tympanoplasty are candidate procedures to promote postoperative aeration.

Longitudinal Change of Varicella-Zoster Virus-Specific Cell-Mediated Immunity in Hunt Syndrome and Bell’s Palsy

Objectives: (1) Compare longitudinal changes of Varicella-zoster virus (VZV)-specific cell-mediated immunity (CMI) in Hunt syndrome with Bell’s palsy using IFN-γ enzyme-linked immunospot (ELISPOT). (2) Examine the role of VZV-specific CMI for VZV reactivation in the facial nerve in Hunt syndrome. Methods: This prospective study was conducted in our tertiary referral hospital between 2010 and 2013. Nineteen Hunt syndrome and 59 Bell’s palsy patients were enrolled. Mononuclear cells isolated from whole blood were incubated with VZV antigen in culture plates for 40 hours. Anti IFN-γ antibody was added and the ELISPOT system counted immunostained spots indicating VZV-specific CMI. The relationship between the spots and days from the onset of palsy were compared between Hunt syndrome and Bell’s palsy patients. Results: Immediately after the onset, the number of spots in the Hunt syndrome group was much lower than in the Bell’s palsy group, indicating low VZV-specific CMI. However, it increased rapidly and showed a strong positive relationship between the number of spots and days from the onset of palsy (r = 0.64) in Hunt syndrome. Several months after the onset, the number of spots in Hunt syndrome decreased gradually. In contrast, the Bell’s palsy group showed no such relationship (r = –0.22). Conclusions: These results suggest that low CMI to VZV may play an important role in VZV reactivation in the facial nerve, thus leading to facial palsy in Hunt syndrome. VZV vaccination is considered to be a candidate to promote VZV-specific CMI for the prevention of Hunt syndrome.