Yutaka Yamamoto

Surgical treatment of 52 cases of auditory ossicular malformations

OBJECTIVEnThe aim of this study was to determine the relationship between hearing improvements and the pathological conditions of auditory ossicular malformations.nnnMETHODSnFifty-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.nnnRESULTSnSuccessful 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.nnnCONCLUSIONSnPostoperative 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.

Evaluation of mastoid air cell system by three-dimensional reconstruction using sagittal tomography of the temporal bone

The mastoid air cell system has been recognized as an important contributor to the pathophysiology of middle ear inflammatory diseases. Various methods of temporal bone imaging have been designed to investigate the correlation between middle ear disease and mastoid pneumatization. In this study, the mastoid air cell system was reconstructed three-dimensionally from sagittal tomographic images of the temporal bone on X-ray films, using a personal computer to evaluate the mastoid pneumatization in a total of 29 patients with chronic otitis media, adhesive otitis media, adhesive-type cholesteatoma, attic cholesteatoma and cholesterol granuloma, and in five normal subjects as controls. Reconstructed three-dimensional images of the mastoid air cell system and its volume were analyzed. The reconstructed images were helpful in recognizing the three-dimensional solid appearance of the mastoid air cell system. The volume of the reconstructed mastoid air cell system was significantly reduced compared with that in the controls in each of the patient groups. Mastoid pneumatization in the patients with adhesive-type cholesteatoma was significantly suppressed compared with that in the adhesive otitis media patients. Interestingly, the adhesive otitis media group showed cell development at the tip of mastoid process, whereas the group of adhesive-type cholesteatoma did not, suggesting a difference in the pathophysiology in the two diseases. We found that three-dimensional reconstruction of the temporal bone using sagittal tomographic images was useful in evaluating the state of mastoid air cell system development in individual cases and in investigating the pathophysiology in middle ear disease.

Acquired cholesteatoma in children: Clinical features and surgical outcome

OBJECTIVEnIn general, cholesteatoma tends to recur more frequently in children than in adults. This has been suggested to be due to immature Eustachian tube function, underdeveloped mastoid air cells, and subsequent repetitive otitis media in children. This study was undertaken to determine the characteristics of acquired cholesteatoma in children by comparison with that in adults.nnnMETHODSnWe retrospectively evaluated 42 children with acquired cholesteatoma (males, 38; females, 4; age range, 3-15 years) using medical records from January 1999 to December 2009 at the Department of Otolaryngology, Niigata University Hospital. The extent of disease was classified according to the Classification and Staging of cholesteatoma proposed by the Japan Otological Society in 2010.nnnRESULTSnNo major differences in stage classification were observed between children and adults. In children with pars flaccida-type cholesteatoma, the epithelium tended to invade from the attic to the mastoid cavity and mesotympanum. In contrast, adult patients with invasion to the mesotympanum were fewer. The rate of disappearance of the stapes superstructure was almost the same in children and in adults. The destruction of the superstructure of the stapes was more common in pars tensa type than pars flaccida type; so it was dependent on the pathology. Postoperative hearing levels were better in children, even in those with widespread lesions. However, the recurrence rate was significantly higher in children.nnnCONCLUSIONSnAcquired cholesteatoma in children showed a wider invasion, and the recurrence rates were higher than that in adults. For patients with a widespread lesion and severe destruction of the ossicles, a two-stage surgery is recommended.

Clinical behavior and pathogenesis of secondary acquired cholesteatoma with a tympanic membrane perforation

Abstract Conclusion: The pathogenesis of secondary acquired cholesteatoma with a tympanic membrane (TM) perforation is very different from that of other types of cholesteatoma. This disease should be clearly categorized as a different type of cholesteatoma. Objective: Primary cholesteatoma generally arises from retraction of the squamous epithelium of the TM. However, in rare cases, epithelial invasion occurs from the edge of the TM perforation and migrates to the medial surface of the TM and middle ear cavity. The aim of this study was to evaluate the clinical features of secondary acquired cholesteatoma with a TM perforation. Methods: We investigated 13 ears that underwent surgical treatment after the diagnosis of secondary acquired cholesteatoma with a TM perforation. Patient backgrounds, the preoperative appearances of TM, intraoperative findings, and histopathological findings were investigated. Results: The average age was much higher than that of patients with other types of cholesteatoma, suggesting that it must require long periods of time to establish the disease. The common area of the epithelial invasion was on the superior part of the TM perforation around the tip of the malleus handle. The tendon of the tensor tympani muscle plays an important role as an extension route for this disease.

Pediatric middle ear cholesteatoma: the comparative study of congenital cholesteatoma and acquired cholesteatoma

This study examined the differences between congenital cholesteatoma (CC) and acquired cholesteatomas (AC) in children by comparing clinical features and treatment courses. This was a retrospective study which retrospectively evaluated 127 children with middle ear cholesteatomas using medical records from January 1999 to December 2012 in the Department of Otolaryngology, Niigata University Hospital. The study comprised 69 and 58 cases of CC and AC, respectively. The main outcome measures include patient backgrounds, the opportunities for consultations, mastoid cell development, intraoperative finding of stapes, surgical procedure and number of surgeries. The average age at operation was 6.4 and 9.8xa0years in CC and AC, respectively. AC was more prevalent in boys. Mastoid development was better in CC than in AC. We adopted a two-stage operation in 17 cases (25xa0%) of CC and in 22 cases (38xa0%) of AC. The repeat surgery rate was 11.6xa0% in CC and 27.6xa0% in AC. Three times as many operations were required for three cases (4.3xa0%) of CC and 10 cases (17.2xa0%) of AC. The lesions in AC were more difficult to control. In the treatment of pediatric middle ear cholesteatoma, we had to keep the outcome in mind.

Practicality analysis of the staging system proposed by the Japan Otological Society for acquired middle ear cholesteatoma: A multicenter study of 446 surgical cases in Japan

OBJECTIVEnThe Objective of this study was to assess the practicality of the cholesteatoma staging system proposed by the Japan Otological Society (JOS) for acquired middle ear cholesteatoma (the 2010 JOS staging system).nnnMETHODSnBetween 2009 and 2010, 446 ears with retraction pocket cholesteatoma underwent primary surgery at 6 institutions in Japan. The extent of cholesteatoma was surgically confirmed, and classified into three stages.nnnRESULTSnThe cholesteatoma affected the pars flaccida in 325 ears (73%), the pars tensa in 100 ears (22%), and both regions combined in 21 ears (5%). The hearing outcome (postoperative air-bone gaps dB) worsened as follows (Stage I, II, III): 84%, 68%, 53% in pars flaccida; 71%, 62%, 30% in pars tensa, and 42% at Stage II, and 50% at Stage III in the combined group. The incidence of residual cholesteatoma increased as follows (Stage I, II, III): 2%, 12%, 23% in pars flaccida; 7%, 30%, 21% in the pars tensa group. The severity of disease was reflected in postoperative hearing and increasing incidence of recurrence rate.nnnCONCLUSIONnThe 2010 JOS staging system is suitable for evaluating initial pathology. It is particularly practical for standardizing reporting of retraction pocket cholesteatoma and for adjusting for the severity of the condition during outcome evaluations. It may also provide information that is useful for counseling patients.

Primary paraganglioma in the facial nerve canal

OBJECTIVEnTo describe primary paraganglioma in the facial nerve canal and discuss the characteristics of facial nerve paraganglioma in contrast with other tumors.nnnCASE REPORTnA 23-year-old man developed gradually progressive right facial palsy as the initial symptom. One year later, he exhibited hearing loss without tinnitus in his right ear. CT demonstrated an enlarged facial nerve canal with irregular bony erosion of the circumference. MRI showed a well-enhanced heterogeneous mass with hypo-intensity spots inside it. During surgery, a blood-rich tumor was observed along the facial nerve: however, extensive bleeding interfered with tumor removal. The surgical specimen demonstrated paraganglioma. The tumor was completely removed in the second surgery in combination with arterial embolization. Facial nerve function was reconstructed with a free muscle flap more than one year following resection.nnnCONCLUSIONnBecause paraganglioma is a blood-rich tumor, it is important to perform angiography and embolization. If preoperative facial nerve palsy is demonstrated, careful management of facial nerve function is needed. Paraganglioma must be considered in the differential diagnosis of a facial nerve tumor.

A method for displaying two images on a screen in distance medical education

This article describes a method for simultaneously displaying several images on a screen during an online multimedia presentation. Users with REALPLAYER software and Web browsers can view images with synchronous audio on their personal computers via the Internet. Medical researchers and physicians often find it useful to compare images after treatment with those before treatment, by displaying several arranged images simultaneously. Medical care providers can browse this type of multimedia content in their offices and universities at their convenience. There presently exist two methods for creating multimedia content with voice and images using RealSystem technology. Electronic lectures of otorhinolaryngology explaining new surgical procedures for patients with chronic otitis media were created with this method and made available to otorhinolaryngologists through the Internet.

A case of lateral sinus insufficiency with acute otitis media: Early surgical intervention for prevention of lateral sinus thrombosis

OBJECTIVEnTo describe a case of lateral sinus insufficiency, presumably occurring just prior to lateral sinus thrombosis (LST), and to discuss the importance of early surgical intervention and the pathophysiology of full-blown LST.nnnCASE REPORTnA 4-year-old boy developed headaches and vomiting after exhibiting typical symptoms of acute otitis media. Contrast-enhanced CT revealed narrowing of the sigmoid sinus medially by gas and low-density material. We diagnosed the patient with suspected LST and consequently performed mastoidectomy. A large amount of bloody pus was found in the mastoid cavity and below the bony sinus plate. Sigmoid sinus blood flow was completely restored after drainage of the hemorrhagic and purulent material, and the patient recovered fully.nnnCONCLUSIONnBecause of the anatomical features of the dural venous sinus, hemorrhage per diapedesis may be strongly associated with the development of LST. In the patient with suspected LST, early diagnosis and surgery prior to the development of intravenous thrombus are key for full recovery from this condition.