Long-term effects of middle ear pressure therapy with the EFET01 device in patients with Ménière's disease and delayed endolymphatic hydrops in Japan

BACKGROUND

Long-term efficacy of middle ear pressure therapy (MEPT) with the EFET01 device in patients in Japan with definitive Ménière's disease (MD) and delayed endolymphatic hydrops (DEH) was evaluated.

OBJECTIVE

To examine the effects of reducing vertigo attacks and improving hearing of MD and DEH patients by using MEPT with the EFET01 device for two years after treatment.

MATERIAL AND METHODS

A retrospective study was conducted of 32 MD patients and 2 DEH patients treated by MEPT with the EFET01 device from December 2018 to April 2021. According to Japan Society for Equilibrium Research (JSER) guidelines, patients were investigated for the frequency of vertigo attacks and change in hearing levels during a period of 6 months before to 18-24 months after start of treatment.

RESULTS

The frequency of vertigo attacks significantly decreased in both MD and DEH patients, and hearing level has remained stable in the majority of our patients after treatment.

CONCLUSION

Our study clarified that MEPT with the EFET01 device was effective in controlling vertigo symptoms of MD and DEH. It should be considered a safe option for patients failing medical treatment.

SIGNIFICANCE

The efficacy of MEPT with the EFET01 was shown over a 2-year follow-up period.

Monitoring pressure changes in the inner ear induced by middle ear pressure therapy with an EFET01 device in guinea pigs

BACKGROUND

As a low-cost, portable, handheld air pressure generation tool not requiring a ventilation tube, the EFET01 device has shown clinical effectiveness for intractable Ménière's disease (MD) patients in Japan. However, no animal studies have investigated changes in inner ear pressure (PI) when applying this device.

OBJECTIVE

To determine the PI properties in response to middle ear pressure therapy (MEPT) induced by the EFET01 in guinea pigs.

MATERIAL AND METHODS

In seven healthy guinea pigs, bi-phasic pressure pulses from -5 to 12 cm H2O were delivered to the external ear canal and transmitted to the middle and inner ear cavities with an intact tympanic membrane. Hydrostatic pressure change in the inner ear perilymphatic compartment was measured by a servo-controlled micropipette system.

RESULTS

From eight successful ears, pressure changes in the middle ear slightly decreased and were instantly transferred to the inner ear. The EFET01 produces a bi-phasic positive/negative pressure pulse, which is approximately twice as large as the monophasic pressure pulse.

CONCLUSION

Our study clarified the EFET01's ability to transmit pressure and verified its effectiveness in MD patients as observed in clinical studies.

SIGNIFICANCE

The PI properties in guinea pig response to MEPT with the EFET01 device were investigated.

Estimated number and prevalence of patients with delayed endolymphatic hydrops in Japan: a nationwide survey

BACKGROUND

Delayed endolymphatic hydrops (DEH) is a rare disease, and the actual number of patients in Japan remains unknown.

OBJECTIVE

To investigate the number and prevalence of patients with DEH in Japan.

METHODS

In total, 781 departments of otolaryngology in Japan were selected for survey by stratified random sampling according to the total number of hospital beds. We sent questionnaires to the target departments and collected data regarding the number of patients with DEH who visited those departments in 2019.

RESULTS

The overall response rate was 68.0% (531 departments). The estimate number of patients with DEH in Japan was 962, and the prevalence was calculated to be 0.8 per 100,000 population.

CONCLUSION

Patients with DEH were extremely rare in Japan.

SIGNIFICANCE

This may be the first nationwide epidemiological study on the number and prevalence of patients with DEH in Japan or in the world.

A 14-year nationwide epidemiological analysis of delayed endolymphatic hydrops in Japan

BACKGROUND

Delayed endolymphatic hydrops (DEH) is an inner ear disease that causes recurrent vertigo in the ipsilateral ear or fluctuating hearing in the contralateral ear due to endolymphatic hydrops secondary to preceding deafness. There are few reports of large, multicentre studies investigating the clinical-epidemiological characteristics of DEH.

OBJECTIVE

This study aimed to clarify the characteristics of DEH in Japan.

METHODS

Clinical data on 662 patients with DEH were analysed by nationwide, multicentre surveys conducted by the Peripheral Vestibular Disorders Research Group of Japan.

RESULTS

The proportion of ipsilateral DEH (IDEH) was slightly higher than that of contralateral DEH (CDEH) at 55.4%. The time delay between onset of precedent deafness and onset of DEH was significantly longer for CDEH than for IDEH. The most common cause of precedent deafness was a disease of unknown cause with onset in early childhood (33.1%). Epidemiological characteristics were not significantly different between CDEH with and without vertigo.

CONCLUSION

DEH appearing to be caused by viral labyrinthitis has a high rate of onset within 40 years of precedent deafness. Clinical and epidemiological characteristics of IDEH, CDEH with vertigo, and CDEH without vertigo were very similar.

SIGNIFICANCE

The clinical-epidemiological characteristics of DEH in Japan were clarified.

12-month effect of middle ear pressure therapy with the EFET01 device for intractable definite Meniere's disease and delayed endolymphatic hydrops after certification by the public health insurance system in Japan

BACKGROUND

Middle ear pressure therapy (MEPT) is effective for intractable vertigo in patients with definite Meniere's disease (MD) and treatment-refractory delayed endolymphatic hydrops (DEH). Four-month MEPT with the EFET01^®, an MEPT device developed in Japan and covered by national health insurance since September 2018, has shown efficacy. However, efficacy and safety after 12 months of treatment, which is appropriate for determining the therapeutic effect of MEPT devices, is unclear.

OBJECTIVES

Examine the therapeutic effect of 12-month MEPT using the ETET01^®.

MATERIAL AND METHODS

Patients underwent MEPT using the EFET01^® from September 2018 to July 2021. Thirty-three patients followed for >12 months were enrolled in this retrospective study. Clinical data were evaluated in the first and second 6-month treatment periods. Data from the second 6-month period were compared with data from an MEPT study using a different device.

RESULTS

MEPT with the EFET01^® significantly improved vertigo in the first period, with further improvement in the second period. The efficacy and safety were comparable to MEPT with other devices.

CONCLUSIONS

MEPT with the EFET01^® is effective for intractable vertigo in patients with definite MD and DEH, and 12-month follow-up is recommended.

SIGNIFICANCE

The efficacy of 12-month MEPT with the EFET01^® was demonstrated.

Novel Application of an Ultrasonic Bone Aspirator for Endoscopic Modified Medial Maxillectomy

Background

Endoscopic modified medial maxillectomy (EMMM) is a surgical technique developed to approach maxillary sinus lesions, such as papilloma and postoperative maxillary cyst, while preserving the postoperative nasal morphology and nasal function. In this technique, a diamond burr is used to remove the bone, which may damage adjacent soft tissue. We developed EMMM using an ultrasonic bone aspirator (UBA) instead of a conventional diamond burr. The purpose of this study was to clarify the effectiveness of the UBA in EMMM in comparison to the conventional diamond burr technique in terms of operative time, intraoperative complications, postoperative symptoms, and recurrence.

Methods

The medical records of all patients who underwent EMMM at Toyama University Hospital between June 2014 and December 2021 were reviewed. Patients who met the inclusion criteria were separated into Group 1, in which the UBA was used for EMMM, and Group 2, in which a drill with a diamond burr was used. Data on patient demographics, operation time, frequency of intraoperative complications and postoperative symptoms, and recurrence were statistically compared between the two groups.

Results

There were no significant differences between the two groups in the patient demographic data, operative time, postoperative symptoms, or frequency of recurrence. The frequency of intraoperative damage to adjacent soft tissues was significantly lower in patients who underwent EMMM with the UBA in comparison to those who underwent EMMM with a conventional diamond burr.

Conclusion

The application of the UBA to EMMM can improve surgical safety and facilitate surgical procedures.

Efficiency of a novel middle ear pressure device for intractable definite Meniere's disease and delayed endolymphatic hydrops after certification by the public health insurance system in Japan

BACKGROUND

Middle ear pressure therapy (MEPT) is effective in treating intractable vertigo in patients with definite Meniere's disease (MD) and delayed endolymphatic hydrops (DEH) refractory to conservative treatment. A novel middle ear pressure device, the EFET01^®, which requires no transtympanic ventilation tubes, was developed in Japan, approved by the Japanese Ministry of Health, Labour and Welfare, and has been used under Japanese national health insurance since September 2018.

OBJECTIVES

To examine short-term therapeutic effect of MEPT using the ETET01^® compared with previous clinical trial results.

METHODS

Patients selected according to Japan Society for Equilibrium Research (JSER) guidelines underwent MEPT using the EFET01 from September 2018 to July 2021, and 44 patients were enrolled in this retrospective study. Clinical data analysed at 4 months after the start of MEPT were compared with those of the previous clinical trial for the EFET01.

RESULTS

MEPT using the EFET01 showed the same therapeutic efficacy as that of the previous clinical trial, i.e. improvement in the intensity and frequency of vertigo with no effect on hearing, even under JSER guidelines for proper use of MEPT.

CONCLUSION

MEPT using the EFET01 provided an effective treatment option for intractable vertigo in patients with definite MD and DEH.

Flap suturing endonasal dacryocystorhinostomy assisted by ultrasonic bone aspirator

BACKGROUND

In the external dacryocystorhinostomy (DCR), a sutured anastomosis technique performed between the nasal mucosal and lacrimal sac flaps reported by Dupuy-Dutemps and Bourguet was the gold standard and was believed to lead to the success of the surgery. However, because of the small working space, a flap suturing technique has not been completely established in endonasal DCR (END-DCR).

OBJECTIVES

The effect of the modified flap suture anastomosis technique using a Sonopet ultrasonic bone aspirator was retrospectively compared to that using a diamond burr in patients with nasolacrimal duct obstruction.

MATERIALS AND METHODS

One hundred ten patients underwent the modified flap suturing technique using the Sonopet, and 30 patients were operated on using a diamond burr.

RESULTS

Successful patency of the lacrimal ostium (LO) was obtained in all patients in both groups. The rates of successful suturing during the operation and of a large diameter of the LO 3 months after the operation were significantly higher in patients in whom the Sonopet rather than the burr was used.

CONCLUSIONS AND SIGNIFICANCE

The Sonopet might offer similar surgical outcome to the traditional microdrill DCR and is a safer means of bone removal in END-DCR in the small working space.

Localized Amyloidosis of the Nasal Mucosa: A Case Report and Review of the Literature

Amyloidosis is a disorder of protein folding in which various proteins automatically aggregate into a highly abnormal fibrillar conformation. Amyloidosis is classified into systemic and localized forms depending on whether the abnormal proteins deposited in several different organs or only a single organ. In localized amyloidosis of the head and neck regions, laryngeal amyloidosis is common; however, localized amyloidosis of the nose is extremely rare. We herein report a case of localized amyloidosis of the nose and review the relevant literature on localized sinonasal amyloidosis. A 41-year-old man presented with a history of severe nasal obstruction, which had persisted for two decades. Nasal endoscopy and imaging studies showed extensive thickening of the bilateral nasal mucosa and diffuse submucosal deposition of calcification. After histopathological and systemic examinations, he was diagnosed with localized amyloidosis of the nasal mucosa. Septoplasty and bilateral inferior turbinoplasty, which consisted of mucosal resection using an ultrasonic bone curette, was performed and his symptoms markedly improved. Localized sinonasal amyloidosis has a good prognosis and surgical resection should be selected as a first-line treatment; however, clinicians should recognize the high probability of recurrence.

Long-term effect of transtympanic intermittent pressure therapy using a tympanic membrane massage device for intractable meniere's disease and delayed endolymphatic hydrops

BACKGROUND

A 12-month follow-up study showed that middle ear pressure treatment with a transtympanic membrane massage (TMM) device had a similar effect to a Meniett device.

OBJECTIVES

The effects of pressure treatment with a TMM device were retrospectively compared to the effects of treatment with a Meniett device in patients with Meniere's disease (MD) and delayed endolymphatic hydrops (DEH) who were followed for a minimum of 24 months.

MATERIALS AND METHODS

Twenty-seven patients were treated with the TMM device and 14 patients were treated with a Meniett device. The insertion of a transtympanic ventilation tube was necessary for the Meniett device but not for the TMM device.

RESULTS

In patients treated with the TMM and Meniett devices, the frequency of vertigo significantly improved at 19-24 months after treatment. The distribution of vertigo at 19-24 months after treatment did not differ between the patients treated with the two types of devices. Pressure treatment for 8 months or more was suitable to achieve remission.

CONCLUSIONS AND SIGNIFICANCE

Middle ear pressure treatment for 8 months or more with a TMM or Meniett device was equally effective and provided minimally invasive treatment options for intractable MD and DEH.

Effects of transtympanic intermittent pressure therapy using a new tympanic membrane massage device for intractable Meniere's disease and delayed endolymphatic hydrops: a prospective study

BACKGROUND

The retrospective study showed that the effect of the middle ear pressure treatment by the tramstympanic membrane massage (TMM) device was similar to that of the Meniett device.

OBJECTIVES

The new TMM device named EFET device was prospectively evaluated in patients with Meniere's disease (MD) and delayed endolymphatic hydrops (DEH) and we compared the effects to the Meniett device.

MATERIALS AND METHODS

23 ears of 19 patients were treated with an EFET device, and 17 ears of 15 patients were treated with the Meniett device. All patients suffering from intractable MD and DEH were treated for 4 months. The insertion of a transtympanic ventilation tube was necessary for the Meniett device, but not the EFET device.

RESULTS

In patients treated by the EFET and Meniett devices, the frequency of vertigo significantly improved after treatment. The distribution of vertigo outcomes at 4 months after treatment did not differ between patients treated with the both devices.

CONCLUSIONS AND SIGNIFICANCE

Middle ear pressure treatment by the EFET device is effective and provides minimally invasive options for intractable MD and DEH like the Meniett device.

Case Report: Response to Intra-arterial Cisplatin and Concurrent Radiotherapy Followed by Salvage Surgery in a Patient With Advanced Primary Sinonasal Low-Grade Non-intestinal Adenocarcinoma

Background: The clinical usefulness of concurrent chemoradiotherapy before surgery in the treatment of primary, locally advanced sinonasal low-grade, non-intestinal type adenocarcinoma (LG non-ITAC) is unclear.

Methods: We present the first case report of the efficacy of super-selective intra-arterial cisplatin (CDDP) infusion concurrent with conventional fractionated radiotherapy (RT) for LG non-ITAC in a Japanese patient.

Results: A white, rugged-marginal mass that was histopathologically diagnosed as LG non-ITAC occupied the right nasal cavity. Based on the imaging findings, including computed tomography, magnetic resonance imaging, and positron emission tomography, the tumor was diagnosed as T4aN0M0, stage IVa. After treatment, the nasal tumor disappeared leaving only a small bulge in the medial wall of the middle turbinate. The patient also underwent right transnasal ethmoidectomy performed as salvage surgery. A histopathological examination revealed that the lesion was replaced by granulation tissue with lymphocytic infiltration and hemosiderin-laden macrophages, and no viable tumor cells remained. In the seven years after treatment, the patient has not experienced any local recurrence or regional or distant metastasis.

Conclusions: Super-selective intra-arterial CDDP infusion concurrent with conventional fractionated RT followed by salvage surgery might be useful for the management of sinonasal LG non-ITAC.

Clinicopathological Features of Thyroid-Like Low-Grade Nasopharyngeal Papillary Adenocarcinoma: A Case Report and Review of the Literature

Thyroid-like low-grade nasopharyngeal papillary adenocarcinoma (TL-LGNPPA) is an extremely rare neoplasm of the nasopharynx. Accordingly, its clinical and pathological characteristics are not well-known. We report a case of TL-LGNPPA and review the relevant literature on TL-LGNPPA. A 38-year-old Japanese woman presented with a history of nasal obstruction that had persisted for 1 month after symptoms of a common cold (e.g., low-grade fever, sore throat, and fatigue). A pedunculated tumor of ~20 mm in diameter was found on the posterior edge of the nasal septum. The tumor was endoscopically resected. Based on careful histopathological and immunohistochemical examinations, it was diagnosed as TL-LGNPPA. At 5 years after surgery, the patient remained disease-free. TL-LGNPPA has a very good prognosis, and complete resection with a sufficient safety margin is recommended as the first-line treatment. The morphological characteristics and immunohistochemical findings, especially TTF-1 positivity and thyroglobulin negativity, are important for the diagnosis.

Lacrimal Drainage System Obstruction Following Inferior Turbinate Surgery

Objective: To provide information on the clinical characteristics and management of an uncommon acquired nasolacrimal drainage system obstruction (NLDSO).

Methods: A patient was treated with microdebrider-assisted endoscopic marsupialization for a cystic lesion located in the synechiae between the inferior turbinate and the lateral wall of the inferior meatus.

Results: A 21-year-old woman suffered from epiphora and purulent discharge 1 week after inferior turbinate surgery. Endoscopy reveled synechiae between the inferior turbinate and the lateral wall of the inferior meatus. Computed tomography-dacrocystography (CT-DCG) showed enlargement of the nasolacrimal duct and cystic accumulation of contrast medium from the lacrimal orifice posteriorly. The patient was treated with nasal endoscopic marsupialization of the cyst and then powered inferior turbinoplasty. Six months after the operation, both endoscopy and CT scan showed a widely patent left inferior meatus and nasolacrimal orifice.

Conclusions: We report the first case of post-operative NLDSO following inferior turbinate surgery. Nasal endoscopy and CT-DCG are useful to diagnose the location of a NLDSO. Otorhinolaryngologists should be aware that surgery may lead to the formation of a NLDSO and that endoscopic marsupialization is a curative treatment for these distal-end NLDSO. NLDSOs are caused by synechiae, which are a complication of inferior turbinate surgery.

Safety management in urgent endonasal trans-sphenoidal surgery for pituitary adenoma during the COVID-19 pandemic in Japan - A case report

We report a 72-year-old woman who required urgent endonasal trans-sphenoidal surgery (eTSS) because of progressive visual field disturbance due to pituitary adenoma, in whom we conducted reverse-transcriptase-polymerase-chain-reaction (RT-PCR) for COVID-19 and chest CT before eTSS. We took care of her by following the rule for suspected infection patient, and safely completed her treatment without medical staff infection. Under COVID-19 pandemic state, essentially careful management including RT-PCR test and chest CT should be taken for the high infection risk surgeries to avoid the outbreak through the hospital. And the cost of RT-PCR test for the patients should be covered by the government budget.

Cerebral Hemodynamic Responses to the Sensory Conflict Between Visual and Rotary Vestibular Stimuli: An Analysis With a Multichannel Near-Infrared Spectroscopy (NIRS) System

Sensory conflict among visual, vestibular, and somatosensory information induces vertiginous sensation and postural instability. To elucidate the cognitive mechanisms of the integration between the visual and vestibular cues in humans, we analyzed the cortical hemodynamic responses during sensory conflict between visual and horizontal rotatory vestibular stimulation using a multichannel near-infrared spectroscopy (NIRS) system. The subjects sat on a rotatory chair that was accelerated at 3°/s² for 20 s to the right or left, kept rotating at 60°/s for 80 s, and then decelerated at 3°/s² for 20 s. The subjects were instructed to watch white stripes projected on a screen surrounding the chair during the acceleration and deceleration periods. The white stripes moved in two ways; in the "congruent" condition, the stripes moved in the opposite direction of chair rotation at 3°/s² (i.e., natural visual stimulation), whereas in the "incongruent" condition, the stripes moved in the same direction of chair rotation at 3°/s² (i.e., conflicted visual stimulation). The cortical hemodynamic activity was recorded from the bilateral temporoparietal regions. Statistical analyses using NIRS-SPM software indicated that hemodynamic activity increased in the bilateral temporoparietal junctions (TPJs) and human MT+ complex, including the medial temporal (MT) area and medial superior temporal (MST) area in the incongruent condition. Furthermore, the subjective strength of the vertiginous sensation was negatively correlated with hemodynamic activity in the dorsal part of the supramarginal gyrus (SMG) in and around the intraparietal sulcus (IPS). These results suggest that sensory conflict between the visual and vestibular stimuli promotes cortical cognitive processes in the cortical network consisting of the TPJ, the medial temporal gyrus (MTG), and IPS, which might contribute to self-motion perception to maintain a sense of balance or equilibrioception during sensory conflict.

Lymphoepithelial carcinoma of the maxillary sinus: A case report and review of the literature

RATIONALE

Most cases of lymphoepithelial carcinoma (LEC) occur in the nasopharynx, and LEC in the sinonasal tract is extremely rare; thus, the clinical characteristics of sinonasal LEC are not well known.

PATIENT CONCERNS

A 63-year-old Japanese man presented with a three-week history of left cheek pain, nasal obstruction and cheek swelling.

DIAGNOSES

Enhanced CT and MRI revealed a tumor of the left maxillary sinus that invaded the left orbit and hard palate, with multiple swollen left cervical lymph nodes. Open biopsy was performed, and the specimen was diagnosed as LEC.

INTERVENTIONS

Alternating chemoradiotherapy (ALCRT) followed by salvage surgery was performed.

OUTCOMES

Our patient has been disease free for 5 years.

LESSONS

A literature review of the epidemiology, etiology, clinical course and management of sinonasal LEC is highlighted. We believe ALCRT followed by salvage surgery to be a highly optimal treatment for sinonasal LEC from the viewpoint of a balance between quality of life and a high curative effect.

[A Case of Infantile Large Parapharyngeal Rhabdomyosarcoma Followed Up for More Than 20 Years]

Rhabdomyosarcomas in the parapharyngeal space are quite rare. We report herein on the case of a 14-month-old boy who was hospitalized with a 2-month history of stridor. On admission, right peritonsillar swelling was noted. CT demonstrated the presence of a large tumor in the right parapharyngeal space. MRI findings showed a right parapharyngeal tumor, 6-cm in diameter. Histopathologic evaluation of the tumor revealed embryonal rhabdomyosarcoma. The clinical staging of the Intergroup Rhabdomyosarcoma Study Group (IRSG) was classified as group III. According to regimen 35 of the IRSG III treatment protocol, radiochemotherapy was started, comprising combination therapy with vincristine, actinomycinD, cyclophosphamide, adriamycin, and carboplatin. The patient tolerated the therapy, but with severe pancytopenia and fever. His sedation during irradiation was difficult. After he received a total dose of 10 Gy and had undergone 9 cycles of chemotherapy, an operation for the rhabdomyosarcoma was performed, resulting in successful removal of the tumor. Doses of 20 Gy were intraoperatively administered. After surgery, residual chemotherapy and irradiation was resumed. The evaluation of the response to therapy was complete remission. After 4 years from the start of therapy, all chemotherapy was halted. At present there is no evidence of recurrence or metastasis, and the patient is a well-developed college student. His sequela following therapy consisted of facial asymmetry, dental abnormalities, and pigmentation of the neck. No adriamycin cardiomyopathy was found.

Cerebral Hemodynamic Responses During Dynamic Posturography: Analysis with a Multichannel Near-Infrared Spectroscopy System

To investigate cortical roles in standing balance, cortical hemodynamic activity was recorded from the right hemisphere using near-infrared spectroscopy (NIRS) while subjects underwent the sensory organization test (SOT) protocol that systematically disrupts sensory integration processes (i.e., somatosensory or visual inputs or both). Eleven healthy men underwent the SOT during NIRS recording. Group statistical analyses were performed based on changes in oxygenated hemoglobin concentration in 10 different cortical regions of interest and on a general linear analysis with NIRS statistical parametric mapping. The statistical analyses indicated significant activation in the right frontal operculum (f-Op), right parietal operculum (p-Op), and right superior temporal gyrus (STG), right posterior parietal cortex (PPC), right dorsal and ventral premotor cortex (PMC), and the supplementary motor area (SMA) under various conditions. The activation patterns in response to specific combinations of SOT conditions suggested that (1) f-Op, p-Op, and STG are essential for sensory integration when standing balance is perturbed; (2) the SMA is involved in the execution of volitional action and establishment of new motor programs to maintain postural balance; and (3) the PPC and PMC are involved in the updating and computation of spatial reference frames during instances of sensory conflict between vestibular and visual information.

Endonasal flap suture-dacryocystorhinostomy (eFS-DCR): a new surgical technique for nasolacrimal duct obstruction (NLDO)

CONCLUSION

Endonasal flap suture-dacryocystorhinostomy (eFS- DCR) is a new and valuable technique for the treatment of nasolacrimal duct obstruction (NLDO). This technique could improve the success rate of endonasal DCR in comparison to external DCR.

OBJECTIVE

The standard procedure for NLDO is DCR. DCR can be performed via either an external or endonasal approach. External DCR is now regarded as the gold standard in the treatment of NLDO because of its higher success rate. However, we report a new endonasal surgical technique, eFS-DCR, and assess its efficacy by comparison with the standard endonasal DCR.

METHODS

We prospectively investigated a series of 62 consecutive patients with NLDO undergoing endonasal DCR. There were two surgical intervention groups: group 1 (24 patients, 28 sites) undergoing endonasal DCR without eFS; and group 2 (38 patients, 47 sites) undergoing eFS-DCR. Study end points were success rate, the ostium diameter (OD) of the lacrimal sac after DCR, and the duration of stent placement. We compared the two groups on these three points.

RESULTS

The success rate was 78.6% (22 of 28 sites) for group 1 (DCR without eFS) and 97.9% (46 of 47 sites) for group 2 (eFS-DCR). The ostium size in patients in group 2 was larger than that in group 1. The median time for the duration of stent placement was 42.5 days for group 1 and 31.5 days for group 2. There was a statistical difference (p < 0.01) in all these parameters between the two groups.

Application of hyperdry amniotic membrane patches without fibrin glue over the bony surface of mastoid cavities in canal wall down tympanoplasty

CONCLUSION

Fibrin glue might be an inessential bioadhesive for attachment of hyperdry amniotic membrane (AM) patches in canal wall down (CWD) tympanoplasty.

OBJECTIVE

To clarify the pliability and adherence capability of human hyperdry AM, the feasibility of fixing hyperdry AM without fibrin glue to the bony surface of the mastoid cavity was evaluated in CWD tympanoplasty.

METHODS

This was a retrospective chart review. In seven ears of seven patients, the AM was simply attached over the bony surface of the mastoid cavity without fibrin glue (AMG(-) group). In 22 ears of 20 other patients, hyperdry AM (11 ears of 11 patients, AMG(+) group) or temporal fascia (11 ears of 9 patients, TFG(+) group) was attached over the bony surface of the mastoid cavity with fibrin glue. Times for graft epithelization were compared among the three groups.

RESULTS

Complete epithelization of the mastoid cavity took place in all patients in all three groups. The mean time to complete epithelization of the graft in the AMG(-) and AMG(+) groups was significantly faster than that in the TFG(+) group (p < 0.05) and was not significantly different between the two AM groups (p > 0.05).

Response to intra-arterial cisplatin and concurrent radiotherapy in a patient with primary mucosal malignant melanoma of the nasal cavity

BACKGROUND

The prognosis for patients with mucosal malignant melanoma (MMM) of the nasal cavity is very poor because of the radioresistance of melanoma cells.

METHODS

We present the first case report of the efficacy of superselective intra-arterial cisplatin (CDDP) infusion concurrent with hypofractionated radiotherapy (RT) for MMM of the nasal cavity.

RESULTS

A pink, polypoid mass, histopathologically diagnosed as an amelanostic melanoma, occupied the right nasal cavity. After the treatment, a nasal tumor disappeared, leaving only a small bulge in the medial wall of the middle turbinate. Histopathologic examination revealed scattered degenerated melanoma cells, remaining only in the small restricted area in the medial surface of the excised middle turbinate. Twelve months after the treatment, the patient has not experienced any local recurrence or regional and distant metastasis.

CONCLUSIONS

The superselective intra-arterial CDDP infusion concurrent with hypofractionated RT might be useful for the management of nasal MMM.

Intermittent pressure therapy of intractable Meniere's disease and delayed endolymphatic hydrops using the transtympanic membrane massage device: a preliminary report

CONCLUSION

Middle ear pressure treatment by the tympanic membrane massage (TMM) device as well as the Meniett device is effective and provides minimally invasive options for intractable vertigo in patients with Meniere's disease (MD) and delayed endolymphatic hydrops (DEH).

OBJECTIVE

The effects of the TMM device were evaluated according to the criteria of the Japan Society for Equilibrium Research (1995) in patients with MD and DEH and compared to those in patients treated with the Meniett device.

METHODS

Twelve ears of 10 patients (MD 8; DEH 2) were treated with the TMM device, while 16 ears of 15 patients (MD 11; DEH 4) were treated with the Meniett device. All the patients had failed to respond to medical treatment including diuretics before each pressure treatment, and were followed up for more than 12 months after treatment. Tympanotomy is necessary before treatment for the Meniett device, not but for the TMM device.

RESULTS

With both devices, the frequency of vertigo after treatment was significantly lower than before treatment (p < 0.05). The time course of vestibular symptoms with the TMM device was not significantly different from that with the Meniett device (p > 0.05). No complications were directly attributable to treatment with the TMM device.

Effect of hyperdry amniotic membrane patches attached over the bony surface of mastoid cavities in canal wall down tympanoplasty

OBJECTIVES

To overcome the lack of the autografts in revision ear surgery, the usefulness of human amniotic membrane (AM) patches as a dressing substitute for fascia grafts of the temporal muscle (temporalis fascia graft) was investigated in canal wall down tympanoplasty.

STUDY DESIGN

Retrospective chart review.

METHODS

In 11 ears of 11 patients, the AM was attached over the bony surface of the mastoid cavity (AM group). In 11 ears of nine patients, the temporalis fascia graft was attached over the bony surface of the mastoid cavity (fascia group). The times for graft epithelization were compared in both groups.

RESULTS

In both groups, complete epithelization of the mastoid cavity took place in all patients. The time of epithelization in the AM group was 32 days, whereas in the fascia group it was 45 days. Complete epithelization of the AM graft was significantly faster than the fascia graft (P < .05).

CONCLUSIONS

Hyperdry AM might be a new useful dressing substitute for temporalis fascia graft due to the reduction in the epithlializing time offered by the AM in revision ear surgery.

[Effect of S-1 in a patient with metastatic eyelid sebaceous carcinoma]

We report a 68-year-old female with a history of repeated right cervical lymph node metastasis secondary to eyelid sebaceous carcinoma. She had undergone right neck dissection due to lymph node metastasis at the department of surgery in an other local hospital. After the orbital exenteration, she underwent multiple operations, including 2 right partial parotidectomy and then total parotidectomy, 4 right cervical lymph node excisions and 1 left upper neck dissection due to lymph node metastasis. Adjuvant chemotherapy with S-1(at a dose of 80 mg per day)alone was applied as tumor dormancy therapy on an outpatient basis. Any adverse events during S-1 medication were observed. New metastatic lesions were not found until 29 months after the beginning of chemotherapy with S-1 alone. Although the effectiveness of S-1 for eyelid sebaceous carcinoma has not been demonstrated, S-1 might be useful in patients with recurrent eyelid sebaceous carcinoma based on our patient's recurrence-free survival.

Global synchronization in the theta band during mental imagery of navigation in humans

Visual mental imagery is critical for successfully navigating the environment, which in turn activates many cortical regions simultaneously. Theta oscillation is implicated in navigation and brain synchronization. In this study, EEG coherence was analyzed during 3 tasks: subjects (1) mentally simulated jogging along the walls of a gym and pressed a button when they imagined arriving at a corner (jogging imagery task), (2) thought of and memorized one digit after pressing a button 5 times and recalled the digits sequentially after pressing the button again (digit imagery task), and (3) pressed a button (button pressing task). The results indicated that theta-wave (4-8 Hz) power was significantly higher in the frontal and parietal regions during the digit and jogging imagery tasks. Coherence at the theta band showed almost no differences between the button pressing and digit imagery tasks. Coherence between the distant regions, especially between the frontal and parieto-occipital regions and between interhemispheric regions, was significantly higher during the jogging imagery task. Increase in theta power during the jogging imagery task reflects working memory load to manipulate internal information. Theta oscillation appears to play an important role in large-scale synchronization to form the functional neuronal networks required for mental navigation.

[Infectious endocarditis associated with multiple mycotic aneurysms; report of a case]

A 68-year-old man was referred to our hospital with infectious endocarditis (IE) of the mitral valve complicated by mycotic aneurysms located in the right middle cerebral artery (MCA) and the superior mesenteric artery (SMA). After coil embolization of the SMA aneurysm during angiography, surgical treatment of the MCA aneurysm was carried out. Antibiotic therapy for Enterococcus faecalis was continued throughout this period. After his IE was controlled, mitral valve repair was performed. The old vegetation on the edge of the anterior leaflet was resected and the defect was covered by transferring the posterior leaflet using the flip-over technique. Since there is no agreement about the optimum treatment of IE associated with multiple mycotic aneurysms, it is important to carefully plan the management of individual cases.

Two Japanese brothers with hereditary gamma-glutamyl transpeptidase deficiency

We report on two Japanese brothers with hereditary deficiency in gamma-glutamyl transpeptidase. The propositus was 48 years old when he first visited our medical center and had a 51-year-old brother. The brothers were both tall and slender and had long limbs; the younger was diagnosed as having Marfan syndrome. Both patients both showed a tendency to retarded mental development. gamma-Glutamyltranspeptidase activity was below the detection limit of 1 IU/L in both patients. Glutathionaemia and glutathionuria were evident in both brothers. The analyses of sulphydryl compounds in the plasma (and serum for certain test items) and urine indicated high concentrations of glutathione, gamma-glutamylcysteine, cysteine and cysteinylglycine. Urine amino acid analysis on an automatic analyser showed a slightly increased excretion of cystine and a large peak in the citrulline position due, at least in part, to thio-compounds.

[Multiple myxoma in the left ventricle and the left atrium]

Left ventricular myxoma is particulary rare. Our case is a 77-year-old female. Transesophageal echocardiography showed a giant tumor in the left atrium. An urgent operation was performed. A giant mass was excised en bloc via a transinteratrial septal approach. Histopathologically it was myxoma. As a transthoracic echocardiography at 1-year postoperation showed a tumor in the left ventricle. A mass was excised en bloc via a vertical approach. Histopathologically it was diagnosed again as myxoma. We looked at the earliest transesophageal echocardiogram again, and found the small tumor on the same area under the posterior mitral leaflet. At the diagnose of cardiac tumor, possibility of multiple formation should be always considered.

Autonomic responses during inhalation of natural fragrance of “Cedrol” in humans

It is well known that odors affect behaviors and autonomic functions. Previous studies reported that some compounds in cedar wood essence induced behavioral changes including sedative effects. In the present study, we analyzed cardiovascular and respiratory functions while subjects were inhaling fumes of pure compound (Cedrol) which was extracted from cedar wood oil. Vaporized Cedrol (14.2+/-1.7 microg/l, 5 l/min) and blank air (5 l/min) were presented to healthy human subjects (n=26) via a face mask, while ECGs, heart rate (HR), systolic blood pressure (SBP), diastolic BP (DBP), and respiratory rates (RR) were monitored. Statistical analyses indicated that exposure to Cedrol significantly decreased HR, SBP, and DBP compared to blank air while it increased baroreceptor sensitivity. Furthermore, respiratory rate was reduced during exposure to Cedrol. These results, along with the previous studies reporting close relationship between respiratory and cardiovascular functions, suggest that these changes in respiratory functions were consistent with above cardiovascular alterations. Spectral analysis of HR variability indicated an increase in high frequency (HF) component (index of parasympathetic activity), and a decrease in ratio of low frequency to high frequency components (LF/HF) (index of sympathovagal balance) during Cedrol inhalation. Furthermore, Cedrol inhalation significantly decreased LF components of both SBP and DBP variability, which reflected vasomotor sympathetic activity. Taken together, these patterns of changes in the autonomic parameters indicated that Cedrol inhalation induced an increase in parasympathetic activity and a reduction in sympathetic activity, consistent with the idea of a relaxant effect of Cedrol.

[Left ventricular papillary fibroelastoma associated with chief complaints of palpitation, general fatigue, and feverish]

Papillary fibroelastoma is one of the commonest benign tumor in the heart. In almost all of cases, symptoms never develop and the tumors are usually discovered coincidentally. Even though papillary fibroelastoma is a benign tumor, surgical extirpation is usually indicated for reason of productive serious complications. The tumors may cause left ventricular outflow obstruction, cerebral embolic infarction, myocardial infarction and even sudden death. The case we reported here is unusual case, because the patient developed symptoms and complaints such as palpitation, feverish and general fatigue. We measured tumor markers, interleukin 6, serotonin and histamine, but none of those was elevated in the blood samples. Surgical removal of the tumor attached to the base of posterior papillary muscle was carried out without causing mitral incompetence, and the pathological findings were compatible with papillary fibroelastoma. After the operation, the both symptoms and complaints disappeared unexpectedly.

Differential activation in the medial temporal lobe during a sound-sequence discrimination task across age in human subjects

To elucidate the brain mechanisms to encode sequential events, event-related potentials (ERPs) were recorded during a sound-sequence discrimination task using young and middle-aged adult subjects. In the task, a series of six or 12 kinds of natural sounds were sequentially presented; 70-80% of the stimuli were presented in a fixed order (Non-target), but the remaining stimuli, in a random order (Target). The subjects were instructed to detect the Targets and press a button at the end of each Target. In a control task, the same sounds were randomly presented (Control), and they were instructed to press the button at the end of each sound. Behavioral results indicated that the young subjects learned the task faster than did the middle-aged subjects. Positive ERP waves were evoked by Targets and Non-targets in the parieto-occipital area around 300-700 ms after stimulus onset. The mean amplitudes during this period in the young subjects were larger in Target than Control conditions, and those in Target condition were larger in the young than middle-aged subjects. Furthermore, the mean amplitudes in the Target condition were significantly correlated with behavioral performance. Equivalent dipoles for the ERPs evoked by Targets were estimated in the medial temporal lobe including the hippocampal formation and parahippocampal gyrus. The results suggest that the ERPs around 300-700 ms latency are involved in sound-sequence information processing. Furthermore, decrease in amplitudes of this positivity in the middle-aged subjects suggests that age-related memory decline is associated with deficits in encoding and retrieval of unfamiliar sequence.

Gamma-band EEGs predict autonomic responses during mental arithmetic

Relationship between gamma-band (20-80 Hz) EEGs and autonomic functions (heart rate, blood pressure, instantaneous lung flow) in a mental arithmetic task (MAT) were investigated. Subjects were instructed to add 2 integers after presentation of audio voices indicating the integers in the MAT, and to listen to the same voices without mental arithmetic in the control task. The gamma-EEGs and autonomic functions coherently changed in response to the voices before mental arithmetic in the MAT. Furthermore, an increase in gamma-EEGs went ahead of the autonomic fluctuation. The results suggest that the gamma-band activity modulates and adjusts peripheral autonomic functions in advance before actual mental activity. This is the first demonstration that cortical gamma-band activity triggers peripheral autonomic responses during mental activity.

Effects of aldehyde dehydrogenase-2 genotype on cardiovascular and endocrine responses to alcohol in young Japanese subjects

The present study was designed to investigate the effects of aldehyde dehydrogenase-2 (ALDH2) genotype on cardiovascular and endocrine responses to alcohol ingestion in young, healthy Japanese subjects. For this purpose, we monitored changes in the electrocardiogram (ECG), blood pressure (BP), finger blood flow (BF) and facial skin temperature (FST) during and after alcohol ingestion (0.4 ml/kg body weight). Spectral analyses of beat-to-beat variations of heart rate (HR), BP and BF were applied. Two major spectral components were examined at low frequency (LF: 0.04-0.15 Hz) and high frequency (HF: 0.15-10.4 Hz) bands for HR and BP variability (BPV). Significant effects for ALDH2 genotype were observed in HR variability (HRV) analysis; HF power of HRV was markedly depressed and the LF/HF ratio was significantly higher with alcohol in ALDH2-deficient (ND) subjects, while ALDH2-normal (NN) subjects did not display such changes. Analysis of BP variability showed increased LF and HF power after alcohol ingestion in the NN subjects, but there were no significant differences between genotypic groups. We also examined BF variability (BFV) in six major spectral components; power of the 0.8-2.2 Hz frequency band was significantly affected by genotype and higher power was observed in the ND subjects. Plasma concentrations of both epinephrine and norepinephrine increased after alcohol ingestion only in the ND subjects. Furthermore, plasma concentrations and urinary excretion of epinephrine, but not norepinephrine, were higher after alcohol ingestion in the ND than in the NN subjects. Blood acetaldehyde levels were about 10-fold higher in the ND than in the NN subjects although blood alcohol levels similarly increased in the ND and NN subjects. Our results also indicated that alcohol ingestion increased secretion of pituitary-adrenal hormones including ACTH, beta-endorphin and cortisol in the ND subjects. The present results along with previous studies suggest that alcohol-induced tachycardia in the ND subjects was probably mediated by acetaldehyde-induced rise in epinephrine secretion from the adrenal medulla and/or changes in the autonomic nervous system. Alcohol-induced relative predominance of cardiac sympathetic activity in the ND subjects might be ascribed partly to increased norepinephrine secretion from sympathetic nerve terminals. Effects of acetaldehyde on these cardiovascular and endocrine systems were discussed in terms of their effects on the central nervous system.