Yasuyuki Hinohira

Incidence of Attic Retraction After Staged Intact Canal Wall Tympanoplasty for Middle Ear Cholesteatoma

Incidence of retraction pocket and recurrent cholesteatoma in the attic after surgery for middle ear cholesteatoma using the staged intact canal wall technique were investigated in 95 ears of 91 patients, all of which had various degrees of bone defect in the tympanic scutum. Surgical procedures employed in the second stage for prevention of attic retraction were classified into three types: Type I, no scutumplasty; Type II, scutumplasty; Type III, scutumplasty plus mastoid obliteration. In 83 ears followed up for more than 1 year after the second stage, such retraction troubles occurred in 2 of 13 ears (15%) in Type I, 8 of 20 ears (40%) in Type II, and 24 of 50 ears (48%) in Type III. Incidence of retraction troubles was higher in Types II and III, probably because these procedures were indicated in ears with large scutum defects. Dislocation and atrophy of the graft materials, together with bone resorption around the bone defect were the main reasons for failure in scutumplasty. Dysfunction of the eustachian tube and traction of the eardrum by the scar tissue behind it may have also contributed to attic retraction. Mastoid obliteration with small blocks of hydroxyapatite was more effective in prevention of retraction troubles than that with pedicled temporalis muscle flap.

Surgical rehabilitation of deafness with partially implantable hearing aid using piezoelectric ceramic bimorpli ossicular vibrator.

We developed two types of implantable hearing aids, a totally implantable hearing aid (TIHA) and a partially implantable hearing aid (PIHA) in 1983. In both types a piezoelectric ceramic bimorph was used as an ossicular vibrator which was coupled to the stapes to transmit sound signals to the inner ear efficiently. Due to technological immaturities, clinical application of the TIHA has not yet been realized. But the PIHA is available for clinical use at present. In the PIHA only the ossicular vibrator is implanted with inner link coil. The rest of components such as microphone, amplifier, battery, and outer link coil remain in their usual location behind the auricle. Since 1984, we have applied the PIHA to 37 patients with mixed deafness. Careful follow-up studies have been conducted on all of them to assess clinical and audiological results. We have confirmed that the device could function safely for more than 10 years affording natural quality of hearing without howling and wearing discomforts. Our studies suggest that the PIHA can be a choice of rehabilitation for mixed deafness due to middle ear diseases which cannot be rehabilitated satisfactorily by either surgical means or a conventional hearing aid. Functional principle of device, indications and surgical methods of implantation were described. Failures and delayed problems we experienced were also presented together with the preventive measures. We believe that an implantable hearing aid of this type will be an otologic breakthrough if substantial technological difficulties are cleared.

Clinical features and outcomes of four patients with invasive fungal sinusitis.

OBJECTIVEnThe frequency of invasive fungal sinusitis (IFS) has increased in recent years with the use of steroids, onset of diabetes mellitus, and the administration of antibacterial agents. We report on the clinical features and outcomes of four patients with IFS involving the cavernous sinus and orbit. Prognostic factors facilitating an early diagnosis are described, and the usefulness of combination therapy involving systemic administration of antifungal agents and surgical intervention is discussed.nnnMETHODSnWe treated four patients with IFS between March 2003 and November 2007 at Ehime University Hospital. Patients were two males and two females, aged from 61 to 74 years (mean 67.8 years).nnnRESULTSnWith regard to clinical symptoms, headache was observed in all patients, and cranial nerve paralysis (visual disturbance, blindness, cheek paresthesia) was seen in 3 patients. β-D-Glucan levels in four patients were high compared with normal values. Aspergillus was histopathologically identified from biopsy specimens in all patients. One patient was complicated with Candida in addition to the Aspergillus infection. Orbital exenteration and ESS were performed in 2 patients as surgical debridement. In all patients, systemic administration of antifungal agents was initiated after surgery.nnnCONCLUSIONSnAll patients received strategic treatment with surgery and systemic administration of anti-fungal agents. The single fatality was due to brain infarction caused by the spread of Aspergillus, and the remaining three patients are still alive. Our observations in these patients suggest that early diagnosis and strategic treatment may improve the prognosis of IFS.

Experimental cholesteatomas arising from autologous free skin grafting in the middle ear cavity

An autologous free skin graft taken from the upper or the lower external ear canal or the auricle was implanted in the otic bulla of 28 guinea pigs. An epidermal cyst simulating middle ear cholesteatoma was successfully produced in 25 (89.3%) animals 8 weeks after grafting. Using this model, the histological reaction of middle ear granulation tissue to the debris was studied. Cysts originated from the auricular skin showed the strongest activity with regard to growth rate, amount of debris produced, and inflammatory reaction to the exposed debris. We conclude that the exposed debris plays an important role in chronic granulomatous inflammation in association with cholesteatoma.

Effects of mastoid cavity obliteration on the growth of experimentally produced residual cholesteatoma

The effects of obliteration of the mastoid cavity on the growth of residual cholesteatoma were histologically studied in an animal model. A dermal cyst was produced by grafting a piece of autologous auricular skin in the otic bulla of 11 guinea-pigs. Three weeks after grafting, part of the cyst wall facing the cavity was removed and the debris accumulated inside was inserted into the surrounding granulation using a micropick. This procedure simulates the growth mechanism of cholesteatoma residue which sometimes occurs after middle ear surgery in human subjects. In six animals, the bulla was then obliterated with plaster of Paris. The remaining five animals were used as controls. Animals were killed for histological study at 2, 4 or 8 weeks postoperatively. Microscopic examinations revealed that in the obliteration group, severe inflammatory reactions were induced in the otic bulla, although the graft epithelium survived there; dermal cyst reformed in only one of six animals. In the controls, cyst reformation was recognized in all animals. This indicated that severe inflammation induced by plaster prevented growth of the graft epithelium in the otic bulla.

Chronic otitis media and tympanoplasty in aged patients.

Results of tympanoplasty in patients over 60 years old were analyzed mainly in terms of hearing and postoperative course. Tympanoplasty was carried out in 78 ears of 67 patients during the last ten years. The following types of tympanoplasty were employed: type I in 34 ears, type III-Columella in 23 ears, type IV-Columella in 13 ears, and other types in 8 ears. The results were compared to those of 145 ears from 119 patients ranging from 20 to 59 years of age who had undergone tympanoplasty during the last 3 years. In tympanoplasty type I, closure of the air-bone gap within 20 dB was attained in 70% of the patients over 60 years old, 90% in the 50-59 year age group, and 100% in the 20-49 year age group. In type III-Columella, these values were 60, 78, and 94%, respectively. During the postoperative follow-up, perforation of the eardrum recurred in 5 of 78 ears (6.4%) in the patients over 60, in 5 of 52 ears (9.6%) in the 50-59 year group, and in 7 of 93 ears (7.5%) in the 20-49 year group. These results suggested that hearing results were worse in patients over 60 than in the other age groups, even though the incidence of graft failure did not greatly differ by age.

Submucous inferior turbinotomy cooperating with combined antrostomies for endonasal eradication of severe and intractable sinusitis

OBJECTIVEnThis paper aims to prove the usefulness of submucous inferior turbinotomy cooperating with the combined middle and the inferior antrostomies in endoscopic endonasal sinus surgery (ESS), enabling the eradication of severe maxillary sinusitis without extranasal approaches. The long-term surgical outcomes of 22 adult patients are presented together with details of this procedure.nnnMETHODSnSubjects comprised 22 adult patients with severe unilateral maxillary sinusitis, showing total opacification on computed tomography and failure of medical treatments preoperatively. Patients who could be managed using conventional ESS methods were excluded. Endoscopic submucous resection of the inferior turbinate bone including the uncinate process was first performed. The procedure aimed to make both the middle and the inferior nasal meatus wide enough to eradicate the sinus disease, cooperating with combined antrostomies.nnnRESULTSnPathology comprised multiple massive polyposis including antrochoanal polyps in 6 and fungal ball in 16 patients. Neither surgical complications nor recurrent disease was seen postoperatively in any patient. Postoperative endoscopic management via both openings was easy and facilitated the restoration of mucosal lining in the sinus.nnnCONCLUSIONnWe proved our new surgical procedure was useful in ESS without any extranasal approaches, although applied to unilateral lesions in the current study. Postoperative management via the middle and the inferior meatal openings helped to facilitate postoperative mucosal healing.

Endoscopic endonasal transseptal approach for localized sphenoid sinus diseases

OBJECTIVEnSurgery for localized sphenoid sinus disease can be performed in different ways. Direct (transnasal) and indirect (transethmoidal) approaches are now prevalent in endoscopic endonasal sinus surgery (ESS) because they are safe and effective. However, the identification or treatment of a sinus is occasionally difficult due to the anatomical variation, postoperative changes, or other reasons. In such difficult cases, we currently used an endoscopic endonasal transseptal approach (EETA) to the sphenoid sinus. The indications, procedures, and outcomes of this surgical method are presented here.nnnPATIENTS AND METHODSnSix of 11 patients with localized sphenoid sinus disease (mycetoma, n=1; mucocele, n=5) were treated using EETA. Surgery was performed under local anesthesia in all subjects. Following endoscopic conventional septoplasty, the sphenoid sinus was opened by perforating the anterior wall through the septoplasty wound. The sphenoid disease was treated through this opening, and then drained to the nasal cavity.nnnRESULTSnThe patients operated on using EETA had no surgical complications or disease recurrence, and the use of navigation or fluoroscopy systems was not required. The mean follow-up period of the patients was 27.7 months (range 18-48 months). Follow-up management included endoscopic examination and computed tomography.nnnCONCLUSIONSnA transseptal approach to the sphenoid sinus with a sublabial incision was once frequently performed in pituitary surgery. We modified the transseptal approach as EETA with the use of an endoscope and endonasal incision. This approach is practical and reliable for ESS, and may serve as an alternative for difficult-to-manage sphenoid sinus disease. EETA can be performed in the office as it can be achieved under local anesthesia without a navigation system.

Endoscopic endonasal reduction surgery for diplopia caused by orbital roof fractures

BACKGROUNDnOrbital roof fractures (ORF) frequently occur together with frontal bone fractures, and can cause diplopia as a sequela. However, ORF have never been treated using endoscopic endonasal reduction surgery.nnnCASEnA 22-year-old woman was injured in a traffic accident and diagnosed with right ORF along with frontal bone fractures. She was referred to us for diplopia 2 weeks after the initial trauma. No facial deformation was seen. Endoscopic endonasal reduction surgery was performed under general anaesthesia. Ethmoidectomy was performed and, subsequently, the anterior superior portion of the medial orbital bone was removed. During the procedure, an ophthalmologist performed eye traction tests until definitive ocular motility improvement was observed.nnnRESULTS AND CONCLUSIONnPostoperatively, diplopia disappeared and no enophthalmos was seen. From both a functional and an aesthetic point of view, the endoscopic endonasal reduction surgery resulted in a satisfactory outcome without having to use any extranasal approaches in this case.

Configuration of experimentally produced cholesteatoma by transplantation of a free skin graft

Residual cholesteatoma was experimentally produced in guinea pigs by transplanting a free skin graft into the middle ear bulla. In group A, the graft was placed on the mucosa after scratching the surface with a pick, while in group B, it was placed on the bone surface following removal of the mucosa and drilling with a diamond burr. The group A procedure was conducted on the left ear and the group B procedure on the right ear in 12 guinea pigs. The animals were sacrificed at two, four and eight weeks after transplantation. In all 12 ears of group A, the graft kept its original flat shape, resembling an open type residue. In eight of 12 ears of group B, the graft grew forming a squamous pearl, while in the remaining four ears it retained a flat shape. The difference in configuration is thought to be due to the amount of granulation around the graft.