Oral Intake Difficulty and Aspiration Pneumonia Assessment Using High-Resolution Manometry

OBJECTIVE

The sequential generation of swallowing pressure (SP) from the nasopharynx to the proximal esophagus is important for the bolus to pass from the oral cavity to the esophagus. The purpose of this study was to investigate the correlation of the SP sequence mode on high-resolution manometry (HRM) with oral intake difficulty and aspiration pneumonia.

METHODS

Consecutive patients with dysphagia who were admitted to our dysphagia clinic between November 2016 and November 2020 were enrolled in this cross-sectional study. We classified the HRM pressure topography data according to the SP sequence mode into type A, normal; B, partially decreased; C, totally decreased; and D, sequence disappeared, and according to the upper esophageal sphincter (UES) during pharyngeal swallowing into type 1, flattening and 2, non-flattening. Clinical dysphagia severity was determined based on oral intake difficulty and aspiration pneumonia.

RESULTS

In total, 202 patients with dysphagia (mean [standard deviation] age, 68.3 [14.5] years; 140 [69.8%] male) were enrolled. Type C (odds ratio [OR], 10.48; 95% confidence interval [CI], 2.89-51.45), type D (OR, 19.90; 95% CI, 4.18-122.35), and type 2 (OR, 6.36; 95% CI, 2.88-14.57) were significantly related to oral intake difficulty. Type C (OR, 3.23; 95% CI, 1.08-11.12) and type 2 (OR, 4.18; 95% CI, 1.95-9.15) were significantly associated with aspiration pneumonia.

CONCLUSION

The failure of sequential generation of SP was associated with higher risk of oral intake difficulty and aspiration pneumonia. These assessments are useful in understanding the pathophysiology and severity of dysphagia and in selecting safety nutritional management methods.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2127-2135, 2024.

Role of Oxidative Stress in Sensorineural Hearing Loss

Hearing is essential for communication, and its loss can cause a serious disruption to one's social life. Hearing loss is also recognized as a major risk factor for dementia; therefore, addressing hearing loss is a pressing global issue. Sensorineural hearing loss, the predominant type of hearing loss, is mainly due to damage to the inner ear along with a variety of pathologies including ischemia, noise, trauma, aging, and ototoxic drugs. In addition to genetic factors, oxidative stress has been identified as a common mechanism underlying several cochlear pathologies. The cochlea, which plays a major role in auditory function, requires high-energy metabolism and is, therefore, highly susceptible to oxidative stress, particularly in the mitochondria. Based on these pathological findings, the potential of antioxidants for the treatment of hearing loss has been demonstrated in several animal studies. However, results from human studies are insufficient, and future clinical trials are required. This review discusses the relationship between sensorineural hearing loss and reactive oxidative species (ROS), with particular emphasis on age-related hearing loss, noise-induced hearing loss, and ischemia-reperfusion injury. Based on these mechanisms, the current status and future perspectives of ROS-targeted therapy for sensorineural hearing loss are described.

Simultaneous disturbance of NHE1 and LOXL2 decreases tumorigenicity of head and neck squamous cell carcinoma

OBJECTIVE

Although there have been brilliant advancements in the practical application of therapies targeting immune checkpoints, achieving success in targeting the microenvironment remains elusive. In this study, we aimed to address this gap by focusing on Na+ / H+ exchanger 1 (NHE1) and Lysyl Oxidase Like 2 (LOXL2), which are upregulated in head and neck squamous cell carcinoma (HNSCC) cells.

METHODS

The malignancy of a metastatic human HNSCC cell line was assessed in a mouse tongue cancer xenograft model by knocking down (KD) NHE1, responsible for regulating intracellular pH, and LOXL2, responsible for extracellular matrix (ECM) reorganization via cross-linking of ECM proteins. In addition to assessing changes in PD-L1 levels and collagen accumulation following knockdown, the functional status of the PD-L1 / PD-1 immune checkpoint was examined through co-culture with NK92MI, a PD-1 positive phagocytic human Natural Killer (NK) cell line.

RESULTS

The tumorigenic potential of each single KD cell line was similar to that of the control cells, whereas the potential was attenuated in cells with simultaneous KD of both factors (double knockdown [dKD]). Additionally, we observed decreased PD-L1 levels in NHE1 KD cells and compromised collagen accumulation in LOXL2 KD and dKD cells. NK92MI cells exhibited phagocytic activity toward HNSCC cells in co-culture, and the number of remaining dKD cells after co-culture was the lowest in comparison to the control and single KD cells.

CONCLUSION

This study demonstrated the possibility of achieving efficient anti-tumor effects by simultaneously disturbing multiple factors involved in the modification of the tumor microenvironment.

Dysphagia in patients with severe COVID-19: a retrospective study

To investigate dysphagia after extubation in patients with severe coronavirus disease 2019 (COVID-19). We retrospectively examined patients with severe COVID-19 treated in our hospital between August 2021 and March 2022. Feeding outcomes were categorized into two groups-(1) total oral intake, and (2) difficulty in oral intake. To assess the feeding outcome, we used modified water-swallowing test (MWST) for all patients. However, in cases where aspiration or recurrent laryngeal nerve palsy was suspected, we conducted the fiberoptic endoscopic evaluation of swallowing after MWST. Patient data were collected from medical records. Forty-six patients with severe COVID-19 were included. Among the 46 patients, 14 (30.4%) experienced difficulties with oral intake. Older age, longer length of hospitalization, duration of mechanical ventilation, tracheostomy, diabetes, and higher serum levels of C-reactive protein (CRP) and procalcitonin (PCT) at the time of intubation were associated with difficulty in oral intake. The rate of difficulty with oral intake in patients with severe COVID-19 was 30.4%, which is not as high as reported in previous studies. Older age, longer duration of mechanical ventilation, tracheostomy, diabetes, and higher levels of CRP and PCT were associated with the prevalence of oral intake difficulty, suggesting that early attention should be paid to high-risk patients who have preexisting deterioration of swallowing function due to aging and comorbidities, or who have prolonged intubation or tracheostomy to prevent aspiration pneumonia.

Coffee and caffeine intake reduces risk of ulcerative colitis: a case-control study in Japan

BACKGROUND AND AIM

Although diet is one of the potential environmental factors affecting ulcerative colitis (UC), evidence is not sufficient to draw definitive conclusions. This Japanese case-control study examined the association between the consumption of coffee, other caffeine-containing beverages and food, and total caffeine and the risk of UC.

METHODS

The study involved 384 UC cases and 665 control subjects. Intake of coffee, decaffeinated coffee, black tea, green tea, oolong tea, carbonated soft drinks, and chocolate snacks was measured with a semiquantitative food-frequency questionnaire. Adjustments were made for sex, age, pack-years of smoking, alcohol consumption, history of appendicitis, family history of UC, education level, body mass index, and intake of vitamin C, retinol, and total energy.

RESULTS

Higher consumption of coffee and carbonated soft drinks was associated with a reduced risk of UC with a significant dose-response relationship (P for trend for coffee and carbonated soft drinks were <0.0001 and 0.01, respectively), whereas higher consumption of chocolate snacks was significantly associated with an increased risk of UC. No association was observed between consumption of decaffeinated coffee, black tea, green tea, or oolong tea and the risk of UC. Total caffeine intake was inversely associated with the risk of UC; the adjusted odds ratio between extreme quartiles was 0.44 (95% confidence interval: 0.29-0.67; P for trend <0.0001).

CONCLUSIONS

We confirmed that intake of coffee and caffeine is also associated with a reduced risk of UC in Japan where people consume relatively low quantities of coffee compared with Western countries.

Effect of intranasal administration of concentrated growth factors on regeneration of the olfactory epithelium in an olfactory dysfunction-induced rat model

OBJECTIVE

The development of treatments that promote the regenerative capacity of the olfactory epithelium (OE) is desirable. This study aimed to evaluate the effects of intranasal administration of concentrated growth factors (CGFs) in a rat model of olfactory dysfunction.

STUDY DESIGN

Animal study.

METHODS

Nineteen male rats were used. Fourteen olfactory dysfunction models were created by intraperitoneal administration of 3-methylindole. We randomly divided the rats from the olfactory dysfunction model after 1 week into the CGF or saline group; CGFs were administered to seven animals and saline to seven animals. Behavioral assessments using the avoidance test were conducted until day 28 after CGF/saline administration. On day 28, histological evaluation was conducted to determine olfactory epithelial thickness and the olfactory marker protein (OMP)-positive cell count. Five animals were intraperitoneally injected with saline as the control group.

RESULTS

The avoidance rate remained decreased until 28 days after CGF/saline administration, and there was no significant difference between the two groups. Olfactory epithelial thicknesses on day 28 were 38.64 ± 3.17 μm and 32.84 ± 4.50 μm in the CGF and saline groups, respectively. OE thickness was significantly thicker in the CGF group than in the saline group (P = 0.013). The numbers of OMP-positive cells were 40.29 ± 9.77/1.0 × 104 μm2 and 31.00 ± 3.69/1.0 × 104 μm2 in the CGF and saline groups, respectively. The number of OMP+ cells in the CGF group was significantly increased compared with that in the saline group (P = 0.009). Both groups showed no improvement compared with the control group (OE thickness: 54.08 ± 3.36 μm; OMP+ cell count: 56.90 ± 9.91/1.0 × 104 μm2).

CONCLUSIONS

The CGF group showed improved olfactory epithelial thickness and OMP-positive cell numbers compared with that in the saline group.

Physical therapy for peripheral facial palsy: A systematic review and meta-analysis

OBJECTIVE

This study aimed to reveal the efficacy of physical therapy for patients with peripheral facial palsy.

METHODS

A literature search was conducted using PubMed, Ichushi-Web, and Cochrane Central Register of Controlled Trials. Published randomized controlled trials comparing the physical therapy versus placebo/non-treatment for peripheral facial palsy such as Bell's palsy, Ramsay Hunt syndrome, and traumatic facial palsy were included for meta-analysis. The primary outcome was non-recovery at the end of the follow-up. Non-recovery was defined according to the authors' definition. The secondary outcomes were the composite score of the Sunnybrook facial grading system and sequelae (presence of synkinesis or hemifacial spasm) at the end of the follow-up. Data was analyzed using Review Manager software and pooled risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) were calculated.

RESULTS

Seven randomized controlled trials met the eligible criteria. The data on non-recovery from four studies was obtained and included 418 participants in the meta-analysis. Physical therapy might reduce non-recovery (RR = 0.51 [95% CI = 0.31-0.83], low quality). Pooling the data of composite score of the Sunnybrook facial grading system from three studies (166 participants) revealed that physical therapy might increase the composite scores (MD = 12.1 [95% CI = 3.11-21.0], low quality). Moreover, we obtained data on sequelae from two articles (179 participants). The evidence was very uncertain about the effect of physical therapy on reduction of sequelae (RR = 0.64 [95% CI = 0.07-5.95], very low quality).

CONCLUSION

The evidence suggested that physical therapy reduces non-recovery in patients with peripheral facial palsy and improves the composite score of the Sunnybrook facial grading system, whereas the efficacy of physical therapy in reducing sequelae remained uncertain. The included studies had high risk of bias, imprecision, or inconsistency; therefore, the certainty of evidence was low or very low. Further well-designed randomized controlled trials are needed to confirm its efficacy.

Development of a proficiency-based training curriculum for beginners in endoscopic endonasal surgery

OBJECTIVE

Precise endoscopic skills are critical for endoscopic endonasal surgery (EES) to ensure patient safety, as well as to succeed as a surgeon. Among these skills, basic skills such as hand-eye coordination and bimanual dexterity are the most important skills for novice surgeons. However, there is no proficiency-based training for the basic skills in EES. In this study, we aimed to develop a proficiency-based training curriculum for beginners in EES using tractable tasks and to assess the curriculum's validity and educational benefits.

METHODS

Training tasks for basic surgical skills of EES were created by experts, using a low-cost and simple simulator. Subsequently, a proficiency-based training curriculum was developed through a preliminary study. The face and content validity of the curriculum was evaluated by expert surgeons. The construct validity was confirmed by comparing the scores of the medical students with those of the experts. In addition, the educational benefits of the curriculum were assessed by comparing the scores of the medical students before and after the implementation of the curriculum.

RESULTS

A proficiency-based training curriculum using six tractable tasks was developed in the preliminary study. Replication of real surgical situation, camera navigation, and instrument operability under endoscopy were all highly appreciated (4.6, 4.6, and 4.8 out of 5 points, respectively), which indicates face validity. The content validity of the curriculum was demonstrated by the results of the questionnaire (4.4 out of 5 points). The curriculum was implemented by 12 medical students. The initial student scores were significantly lower than the expert scores (mean score: 61.9 vs. 100.0, p < 0.001), and each coefficient of variation of the student scores was higher than that of the expert scores (p < 0.01), supporting the construct validity of the curriculum. The mean student composite scores were statistically improved after the training (61.9 vs. 93.3, p < 0.0001). In addition, improvement of five other medical students' EES skills through this training curriculum was confirmed in cadaver dissection (1.7 vs. 3.7, p < 0.0001).

CONCLUSION

The validity of the proficiency-based training curriculum developed through the preliminary study was established based on the questionnaire of experts and the difference between student and expert scores. In addition, the educational benefits were demonstrated by the students' learning curves. The low-cost and simple simulator seems appropriate as an entry model for beginners in EES, and this curriculum can provide rapid intervention and objective assessment of basic skills in EES.

The Association Between Dehydration and the Prognosis of Sudden Sensorineural Hearing Loss

Background

There is an urgent need to identify undetermined risk factors for sudden sensorineural hearing loss (SSNHL) for the development of effective treatment strategies. SSNHL is likely associated with vascular insufficiency; however, no study has evaluated the relationship between dehydration and SSNHL.

Objective

This study aimed to investigate the role of dehydration in the development and prognosis of sudden sensorineural hearing loss.

Study Design

Retrospective case-control study.

Setting

Secondary referral hospital.

Patients and Interventions

This was a comparative study that compared dehydration parameters between healthy subjects without SSNHL (n = 94) and patients with SSNHL (n = 94). The study also evaluated the effect of dehydrated conditions on the prognosis of SSNHL.

Main Outcome Measures

We compared dehydration parameters, such as the blood urea nitrogen-to-creatinine ratio (BUN/Cre) and plasma osmolality (Posm), between matched healthy subjects without SSNHL and patients with SSNHL. To evaluate the effect of dehydrated conditions on the SSNHL prognosis, the SSNHL patients were divided into 2 groups based on the cutoff value obtained from the receiver operating characteristic analysis: hydrated (n = 50; BUN/Cre <21.4) and dehydrated (n = 44; BUN/Cre ≥21.4) groups. Subsequently, the severity and prognosis of SSNHL were analyzed.

Results

The dehydration parameters, BUN/Cre and Posm, were significantly higher in patients with SSNHL than in healthy subjects. The initial hearing levels and SSNHL grades were worse in the dehydrated group than in the hydrated group. Moreover, a dehydrated condition (BUN/Cre ≥21.4) was associated with a poor SSNHL prognosis in all models of the multiple logistic regression analysis.

Conclusions

The dehydration parameters of BUN/Cre and Posm were higher in patients with SSNHL than in healthy subjects. Additionally, a dehydrated condition (BUN/Cre ≥21.4) was an independent prognostic factor for SSNHL. Level of evidence: Level 4.

The Landscape of MYB/MYBL1- and Peri-MYB/MYBL1-Associated Rearrangements in Adenoid Cystic Carcinoma

Approximately 60% of adenoid cystic carcinoma (AdCC) cases are positive for MYB::NFIB or MYBL1::NFIB, whereas MYB/MYBL1 oncoprotein, a key driver of AdCC, is overexpressed in most cases. Juxtaposition of superenhancer regions in NFIB and other genes into the MYB/MYBL1 locus is an attractive oncogenic hypothesis for AdCC cases, either negative or positive for MYB/MYBL1::NFIB. However, evidence supporting this hypothesis is insufficient. We examined 160 salivary AdCC cases for rearrangements in MYB/MYBL1 loci and peri-MYB/MYBL1 areas (centromeric and telomeric areas of 10 Mb each) using formalin-fixed, paraffin-embedded tumor sections. For the detection of the rearrangements, we employed conventional fluorescence in situ hybridization split and fusion assays and a 5 Mb fluorescence in situ hybridization split assay. The latter is a novel assay that enabled us to detect any possible splits within a 5 Mb distance of a chromosome. We found MYB/MYBL1- and peri-MYB/MYBL1-associated rearrangements in 149/160 patients (93%). AdCC cases positive for rearrangements in MYB, MYBL1, the peri-MYB area, and the peri-MYBL1 area numbered 105 (66%), 20 (13%), 19 (12%), and 5 (3%), respectively. In 24 peri-MYB/MYBL1 rearrangement-positive cases, 14 (58%) were found to have a juxtaposition of the NFIB or RAD51B locus into the MYB/MYBL1 loci. On comparing with a tumor group positive for MYB::NFIB, a hallmark of AdCC, other genetically classified tumor groups had similar features of overexpression of the MYB transcript and MYB oncoprotein as detected by semiquantitative RT-qPCR and immunohistochemistry, respectively. In addition, clinicopathological and prognostic features were similar among these groups. Our study suggests that peri-MYB/MYBL1 rearrangements may be a frequent event in AdCC and may result in biological and clinicopathological consequences comparable to MYB/MYBL1 rearrangements. The landscape of MYB/MYBL1 and peri-MYB/MYBL1 rearrangements shown here strongly suggests that juxtaposition of superenhancers into MYB/MYBL1 or peri-MYB/MYBL1 loci is an alteration that acts as a key driver for AdCC oncogenesis and may unify MYB/MYBL1 rearrangement-positive and negative cases.

Prognostic scores for patients with salivary adenoid cystic carcinoma without lymph node metastasis

Adenoid cystic carcinoma (AdCC) of salivary gland grows relatively slowly, but occasionally develops distant metastasis. Although cervical lymph node metastasis (LNM) has been reported as a strong prognostic factor, most of AdCC do not have LNM. In this study, we investigated the prognostic factors to predict disease free survival (DFS), distant metastasis free survival (DMFS), and overall survival (OS) for 175 patients surgically treated for AdCC without LNM, and developed prognostic score (PS) determined as number of positive prognostic factors. The following emerged as significant prognostic factors: positive surgical margin in DFS, pT3/4 and positive surgical margin in DMFS, and positive surgical margin and high-histological grade in OS. 10-year DFS rates were 56.4% in PS0, and 19.1% in PS1 (p < 0.0001). 10-year DMFS rates were 86.3% in PS0, 56.4% in PS1, and 30.7% in PS2 (p < 0.0001). 10-year OS rates were 100% in PS0, 73.3% in PS1, and 38.8% in PS2 (p < 0.0001).

Glomangiopericytoma with CTNNB1 mutation

Glomangiopericytoma (GPC) is a rare tumour, accounting <0.5% of all nasal cavity tumours. It is classified as borderline malignant to indolent and is associated with perivascular myeloid cells. We report a case of GPC in a woman in her 80s who presented with nasal obstruction. The tumour originated from the nasal septum and was resected via endoscopic sinus surgery. Histopathological examination revealed dense spindle-shaped to oval-shaped mesenchymal cells forming tumour nodules with staghorn-like vessel formation. Immunohistochemical analysis revealed that the tumour cells were positive for α-smooth muscle actin, CD34, β-catenin and cyclin D1, whereas they were negative for STAT6. The percentage of Ki-67-positive cells was approximately 2%. Recent studies have demonstrated a high frequency of β-catenin (CTNNB1) mutations in GPC. We report a case of GPC where identifying CTNNB1 mutations (c.94G>C, p.D32H) was crucial for establishing a definitive diagnosis.

The dynamics of deglutition during head rotation using dynamic 320-row area detector computed tomography

Objective

We aimed to elucidate the dynamics of deglutition during head rotation by acquiring 320-row area detector computed tomography (320-ADCT) images and analyzing deglutition during head rotation.

Methods

This study included 11 patients experiencing globus pharyngeus. A 320-ADCT was used to acquire images in two types of viscosity (thin and thick), with the head rotated to the left. We measured the movement time of deglutition-related organs (soft palate, epiglottis, upper esophageal sphincter [UES], and true vocal cords) and pharyngeal volume (bolus ratio at the start of UES opening [Bolus ratio], pharyngeal volume contraction ratio [PVCR], and pharyngeal volume before swallowing [PVBS]). A two-way analysis of variance was performed for statistical analysis, and all items were compared for significant differences in terms of head rotation and viscosity. EZR was used for all statistical analyses (p-value <.05).

Results

Head rotation significantly accelerated the onset of epiglottis inversion and UES opening compared with no head rotation. The duration of epiglottis inversion with the thin viscosity fluid was significantly longer. The bolus ratio increased significantly with thick viscosity. There was no significant difference in viscosity and head rotation in terms of PVCR. PVBS increased significantly with head rotation.

Conclusion

The significantly earlier start of epiglottis inversion and UES opening due to head rotation could be caused by: (1) swallowing center; (2) pharyngeal volume; and (3) pharyngeal contraction force. Thus, we plan to further analyze swallowing with head rotation by combining swallowing CT with manometry and examine its relationship with pharyngeal contraction force.

Level of Evidence

3b.

Intermittent environmental exposure to hydrogen prevents skin photoaging through reduction of oxidative stress

AIM

Molecular hydrogen is not only expected to be used as an energy-generating resource, but also to have preventive effects on a variety of clinical manifestations related to oxidative stress through scavenging radicals or regulating gene expression. In the current study, we investigated the influence of intermittent environmental exposure to hydrogen gas at a safe concentration (1.3%) on photoaging using an ultraviolet A (UVA)-irradiated murine model.

METHODS

To mimic the expected human daily activity cycle, UVA exposure in the daytime and hydrogen exposure in the night-time, an original design, UVA-transmission, hydrogen-exposure system was established. Mice were bred under experimental conditions of UVA irradiation and normal air for 8 h (outdoor time 09.00-17.00 hours), and UVA non-irradiation and inhalation of hydrogen gas for 16 h (indoor time 17.00-09.00 hours), and the daily cycle was continued for up to 6 weeks. The progression of photoaging, including morphological changes, collagen degradation and UVA-related DNA damage, was evaluated.

RESULTS

Intermittent administration of hydrogen gas by our system prevented UVA-induced epidermal signs, such as hyperplasia, melanogenesis and appearance of senescence cells, and UVA-induced dermal signs, such as collagen degradation. In addition, we detected attenuation of DNA damage in the hydrogen exposure group as indirect evidence that intermittent exposure to hydrogen gas reduced oxidative stress.

CONCLUSIONS

Our findings support the notion that long-term, intermittent environmental exposure to hydrogen gas in daily life has a beneficial effect on UVA-induced photoaging. Geriatr Gerontol Int 2023; ••: ••-••.

Cricotracheostomy for patients with severe COVID-19: A case control study

Background

Tracheostomy is an important procedure for the treatment of severe coronavirus disease-2019 (COVID-19). Older age and obesity have been reported to be associated with the risk of severe COVID-19 and prolonged intubation, and anticoagulants are often administered in patients with severe COVID-19; these factors are also related to a higher risk of tracheostomy. Cricotracheostomy, a modified procedure for opening the airway through intentional partial cricoid cartilage resection, was recently reported to be useful in cases with low-lying larynx, obesity, stiff neck, and bleeding tendency. Here, we investigated the usefulness and safety of cricotracheostomy for severe COVID-19 patients.

Materials and methods

Fifteen patients with severe COVID-19 who underwent cricotracheostomy between January 2021 and April 2022 with a follow-up period of ≥ 14 days were included in this study. Forty patients with respiratory failure not related to COVID-19 who underwent traditional tracheostomy between January 2015 and April 2022 comprised the control group. Data were collected from medical records and comprised age, sex, body mass index, interval from intubation to tracheostomy, use of anticoagulants, complications of tracheostomy, and decannulation.

Results

Age, sex, and days from intubation to tracheostomy were not significantly different between the COVID-19/cricotracheostomy and control/traditional tracheostomy groups. Body mass index was significantly higher in the COVID-19 group than that in the control group (P = 0.02). The rate of use of anticoagulants was significantly higher in the COVID-19 group compared with the control group (P < 0.01). Peri-operative bleeding, subcutaneous emphysema, and stomal infection rates were not different between the groups, while stomal granulation was significantly less in the COVID-19 group (P = 0.04).

Conclusions

These results suggest that cricotracheostomy is a safe procedure in patients with severe COVID-19.

Effect of hormonal therapy on the otoconial changes caused by estrogen deficiency

Benign paroxysmal positional vertigo (BPPV) is associated with menopause and/or osteopenia. Morphological changes in the otoconial layer have been reported after ovariectomy (OVX). Moreover, hormone replacement therapy decreases BPPV risk. However, knowledge concerning the effect of hormonal therapy on the otoconial changes caused by estrogen deficiency is limited. We aimed to examine the effect of hormonal therapy on otoconial changes caused by estrogen deficiency. We hypothesized that hormonal therapy could reduce otoconial changes caused by OVX. Eight-week-old C57BL/6 mice were divided into four groups: sham operation with implantation of vehicle (sham + v), OVX with implantation of vehicle (OVX + v), OVX with implantation of estradiol (E2) (OVX + E2), and OVX with implantation of raloxifene (RAL) (OVX + RAL) groups. Otoconial layer volume was measured by micro-CT at 4 weeks after OVX or the sham operation. The otic bullae were removed; immunohistochemistry was performed for estrogen receptor alpha and 4-hydroxynonenal. Otoconial layer volume was significantly higher in the OVX + v than in the sham + v group. E2 and RAL significantly reduced these changes in the endometrial layer. The staining of estrogen receptor alpha and 4-hydroxynonenal were stronger in the OVX + v than in the sham + v group but equal in the sham + v, OVX + E2, and OVX + RAL groups. These results indicate that E2 and RAL are effective against morphological changes of the otoconial layer caused by estrogen deficiency via oxidative stress reduction.

A double-blinded, randomized controlled clinical trial of hydrogen inhalation therapy for idiopathic sudden sensorineural hearing loss

Background

Hydrogen (H₂) has been reported to be effective in reducing hearing loss due to several causes in animal studies. However, no study has examined the effectiveness of H₂ in treating hearing loss in humans. Thus, we investigated whether H₂ is effective for the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL).

Materials and methods

We conducted a double-blind randomized controlled trial at six hospitals between June 2019 and March 2022. The study protocol and trial registration have been published in the Japan Registry of Clinical Trials (jRCT, No. jRCTs06119004). We randomly assigned patients with ISSNHL to receive either H₂ (H₂ group) or air as a placebo (control group) through inhalation combined with the administration of systemic glucocorticoids and prostaglandin E1. The primary outcome was the hearing threshold and changes in hearing threshold 3 months after therapy. In contrast, the secondary outcomes included the proportion of patients with a good prognosis (complete recovery or marked improvement).

Results

Sixty-five patients with ISSNHL (31 and 34 in the H₂ and control groups, respectively) were included in this study. The hearing threshold 3 months after treatment was not significantly different between the groups; 39.0 decibels (dB) (95% confidence interval [CI]: 28.7-49.3) and 49.5 dB (95% CI: 40.3-58.7) in the H₂ and control groups, respectively. In contrast, the changes in hearing threshold 3 months after treatment was 32.7 dB (95% CI: 24.2-41.3) and 24.2 dB (95% CI: 18.1-30.3) in the H₂ and control groups, respectively. Consequently, the changes in hearing threshold were significantly better in the H₂ group than in the control group (P = 0.048). However, no adverse effects due to the inhalation of H₂ gas have been reported.

Conclusion

This is the first study to investigate the efficacy of H₂ for the treatment of ISSNHL in humans. The results suggest that H₂ therapy may be effective for ISSNHL treatment.

Clinical trial registration

[https://jrct.niph.go.jp/re/reports/detail/10442], identifier [jRCTs06119004].

Laryngeal complications after endotracheal intubation and prone positioning in patients with coronavirus disease 2019

Objectives

Laryngeal complications have been reported after endotracheal intubation and prone positioning in patients with critical coronavirus disease 2019 (COVID-19), but their association is unclear. In this study, we investigated the rate of laryngeal complications in patients with COVID-19 compared to an alternative condition (control group).

Methods

We retrospectively analyzed the data of 40 patients who underwent endotracheal intubation for either COVID-19 or an alternative condition (control group). Data on age, sex, body mass index (BMI), cardiovascular disease (CVD) risk factors, use of prone therapy, duration of endotracheal intubation, and duration from extubation/tracheostomy to laryngeal evaluation were collected from medical records.

Results

There were no significant differences in BMI, frequency of CVD risk factors, duration of endotracheal intubation, or duration from extubation/tracheostomy to laryngeal evaluation between the two groups. In the COVID-19 group, all patients adopted the prone position. In comparison, only one patient in the control group adopted the prone position. Significant differences were observed between the two groups regarding the incidence of vocal fold immobility and laryngeal granuloma.

Conclusion

Laryngeal complications were more common in the COVID-19 group than in the control group. Prone positioning may be a risk factor for these complications.

Level of Evidence

4.

Two-year seroprevalence surveys of SARS-CoV-2 antibodies among outpatients and healthcare workers in Japan

We have conducted two-year seroprevalence surveys of SARS-CoV-2 antibodies among outpatients and healthcare workers (HCWs) at Ehime University Hospital. We collected data for outpatients and HCWs in June 2020 (1st survey), December 2020 (2nd survey), July 2021 (3rd survey) and December 2021 (4th survey) focusing on demographics, occupation, and the seroprevalence of anti-SARS-CoV-2 antibodies. Blood samples were obtained from randomly selected outpatients who visited our hospital for medical care and from HCWs undergoing regular medical checks with opt-out informed consent. SARS-CoV-2 antibody positivity was evaluated using two laboratory-based quantitative tests. The total number of participants enrolled was 6,369 (1st survey: 1000 outpatients and 743 HCWs, 2nd survey: 1000 outpatients and 407 HCWs, 3rd survey: 1000 outpatients and 804 HCWs, 4th survey: 1000 outpatients and 415 HCWs). The prevalence of SARS-CoV-2 antibodies among outpatients and HCWs was 0~0.1% and 0~0.124% during the research period, respectively, and changed little over time. These findings suggest that the magnitude of COVID-19 infection during the pandemic among outpatients and HCWs in this rural hospital might have been small.

IL12B rs6887695 polymorphism and interaction with alcohol intake in the risk of ulcerative colitis in Japan

BACKGROUND

The interleukin (IL)-23/Th17 pathway plays a critical role in ulcerative colitis (UC). The IL-12p40 subunit, which is shared by IL-23 and IL-12, is encoded by the IL12B gene. The current case-control study investigated the association between IL12B SNP rs6887695 and the UC risk.

METHODS

There were 384 cases within 4 years of UC diagnosis and 661 controls who were enrolled. Adjustments were made for sex, age, pack-years of smoking, alcohol consumption, history of appendicitis, family history of UC, education level, and body mass index.

RESULTS

Subjects with the GG IL12B SNP rs6887695 genotype had a significantly increased risk of UC compared with those with the CC genotype (adjusted odds ratio [AOR], 1.60; 95% confidence interval [CI], 1.08-2.36). This positive association was also significant using the additive and recessive models (AOR, 1.25; 95% CI, 1.03-1.52; AOR, 1.50; 95% CI, 1.08-2.09, respectively). An independent inverse relationship was observed between ever alcohol consumption and the UC risk in those with the CC genotype while no significant association was found in those with at least one G allele (P for interaction = 0.0008).

CONCLUSIONS

IL12B SNP rs6887695 was significantly associated with UC. The influence of alcohol consumption might rely on rs6887695.

Usage of cadavers in surgical training and research in Japan over the past decade

The “Guidelines for Cadaver Dissection in Education and Research of Clinical Medicine” drafted by the Japan Surgical Society (JSS) and the Japanese Association of Anatomists in 2012 helped dispel legal concerns over cadaver surgical training (CST) and the usage of donated human bodies for research and development (R&D) in the country. Subsequently, in the fiscal year 2018, the Ministry of Health, Labour and Welfare increased the funding for CST, prompting its wider implementation. This study analyzed data obtained in 2012–2021 through the reporting system of the JSS-CST Promotion Committee to map the usage of cadavers for clinical purposes, specifically education and R&D, in Japan. We found that the number of medical universities using cadavers for CST and R&D programs was just 5 in 2012, and it reached 38 for the decade. Thus, about half of Japan’s medical universities implemented such programs over the period. Meanwhile, the total number of programs was 1,173. In the clinical field, the highest number of programs were implemented in orthopedics (27%), followed by surgery (21%), and neurosurgery (12%). Based on the purpose, the most common objective of the programs (approximately 70%) was acquiring advanced surgical techniques. Further, the highest number of programs and participants were recorded in 2019 (295 programs, 6,537 participants). Thus, the guidelines helped expand cadaver usage for clinical purposes in Japan. To further promote the clinical usage of cadavers in medical and dental universities throughout Japan, sharing know-how on operating cadaver laboratories and building understanding among the general public is recommended.

Active and passive smoking and risk of ulcerative colitis: A case-control study in Japan

BACKGROUND AND AIM

Although an inverse relationship between current smoking and the development of ulcerative colitis (UC) has been shown in North America and Europe, evidence is limited in Asian countries, where the incidence of UC is rapidly increasing. This Japanese case-control study examined the association between active and passive smoking and risk of UC.

METHODS

A self-administered questionnaire was used to obtain information on smoking and potential confounding factors in 384 cases with a diagnosis of UC within the past 4 years and 665 controls.

RESULTS

Compared with having never smoked, having ever smoked was associated with an increased risk of UC (adjusted odds ratio [OR] = 1.70, 95% confidence interval [CI]: 1.23-2.37). No association was observed between current smoking and risk of UC, but former smokers had a significant elevation in risk (adjusted OR = 2.40, 95% CI: 1.67-3.45). There was a positive dose-response relationship with pack-years smoked (P for trend = 0.006). Among never smokers, passive smoking exposure at home was significantly associated with an increased risk of UC (adjusted OR = 1.90, 95% CI: 1.30-2.79). A significant dose-response gradient was also observed between pack-years of passive smoking at home and risk of UC (P for trend = 0.0003).

CONCLUSIONS

We confirmed that former smoking elevated the risk of UC, whereas an inverse association between current smoking and the risk of UC did not reach a statistically significant level. Passive smoking may be associated with an increased risk of UC.

Development of a simple evaluation instrument for liquid thickness measurement

Simple methods, such as the line spread test (LST), are often used to evaluate thickened liquids in clinical settings. Although it is desirable for these simple methods to be rapid, even the LST requires approximately 1 min to complete the evaluation. Herein, we aimed to shorten this time by developing a new simple instrument for evaluating thickened liquids considering the fluid engineering perspective with improved funnel design and evaluation methods. A thickened liquid was prepared with a xanthan gum-based thickening agent and water. Samples with viscosities of approximately 50, 150, 300, and 500 mPa∙s were prepared. For evaluation, 30 ml of the sample was injected manually with the outlet closed. The outlet was then opened to allow the liquid to fall as soon as the evaluation began. The time taken for the water surface of the liquid to move 50 mm from the starting point to the target point was measured eight times using a stopwatch, and the average was taken as the evaluation time. The instrument took 2.22-3.29 s, 3.29-9.16 s, and 9.16-23.14 s to classify mildly thick, moderately thick, and extremely thick samples, respectively. This method enabled extremely thick samples to be evaluated in 23 s, which is 27 s less than the time taken by the conventional funnel method. Verification results showed that this developed evaluation instrument for thickened liquids could perform classification according to the criteria of the Japanese Dysphagia Diet 2013. We aim to improve its design for clinical use in the future.

Intratympanic Insulin-like Growth Factor-1 Administration Via the Otic Bulla in a Severe Facial Paralysis Model

HYPOTHESIS

We investigated the treatment effect of intratympanic insulin-like growth factor-1 (IGF-1) on severe facial paralysis in guinea pigs.

BACKGROUND

The use of regenerative medicine involving growth factors has been reported in the treatment of peripheral nerve diseases. IGF-1 plays a crucial role in nerve regeneration.

METHODS

We performed the following procedures on guinea pigs. In the normal group (n = 7), no procedure was performed. In the saline (n = 7) and IGF-1 (n = 7) groups, facial paralysis was induced by freezing of the facial canal. Subsequently, in the saline and IGF-1 groups, a gelatin hydrogel impregnated with 100 μL saline and 400 μg/100 μL IGF-1, respectively, was placed in the facial canal. Facial nerve functions were evaluated using three test batteries: facial movement observation, electrophysiological testing, and histological assessment.

RESULTS

At 10 weeks postoperatively, the facial movement scores for the IGF-1 group were improved compared to those in the saline group. The conductive velocity was significantly faster in the IGF-1 group than in the saline group. There was a significant between-group difference in the nerve fiber number and myelin thickness.

CONCLUSION

Intratympanic IGF-1 administration improved facial nerve regeneration. This novel method could provide prompt ambulatory regenerative treatment and reduce the incidence of poor recovery in patients with severe facial paralysis.

Higher number of teeth is associated with decreased prevalence of hearing impairment in Japan

BACKGROUND/OBJECTIVES

There is limited evidence on the association between tooth loss and hearing impairment (HI). The present cross-sectional study investigated the association between tooth loss and the prevalence of HI in 1004 Japanese adults aged 36 to 84 years.

METHODS

HI was defined as present when pure-tone average was > 25 dB at a frequency of 0.5, 1, 2, and 4 kHz in the better hearing ear. Visual oral examinations were performed. Adjustments were made for age, sex, smoking status, leisure-time physical activity, hypertension, dyslipidemia, diabetes mellitus, history of depression, body mass index, waist circumference, employment, education, and household income.

RESULTS

Of 1004 study subjects, the prevalence of HI was 24.8% (n = 249). Compared with having 28 teeth, having < 22 teeth, but not having 26 to < 28 or 22 to < 26 teeth, was associated with an increased prevalence of HI; the multivariate adjusted ORs (95% CI) of having 26 to < 28, 22 to < 26, and < 22 teeth were 1.41 (0.85-2.38), 1.51 (0.90-2.57), and 1.96 (1.18-3.30), respectively (p for trend = 0.01).

CONCLUSIONS

The results suggest that tooth loss may be associated with an increased prevalence of HI.

Comparison of the Signal Intensity of Vestibular Schwannoma Between Growing and Nongrowing Tumors

OBJECTIVES/HYPOTHESIS

To determine the relationship between signal intensity on gadolinium (Gd)-enhanced magnetic resonance images and growth of vestibular schwannomas (VSs).

STUDY DESIGN

Cross-sectional study.

METHODS

In this cross-sectional study, we retrospectively reviewed the data of 31 patients with VSs who underwent magnetic resonance imaging (MRI). The mean signal intensities within the regions of interest in the tumor, pons, and temporal muscles were measured on Gd-enhanced T1-weighted MRI. Relative intensity ratios were calculated as follows: T/N pons ratio (T/Np) is the tumor signal intensity/pons signal intensity and T/N muscle ratio (T/Nm) is the tumor signal intensity/temporal muscle signal intensity. Volume measurements were used to assess the tumor size. Growth rate was determined by assessing previous imaging studies. Growing VS was defined as a tumor with a growth rate >100 mm³ /year.

RESULTS

The mean (standard deviation) T/Np and T/Nm were 1.47 (0.27) and 1.50 (0.24), respectively, in nongrowing tumors and 1.78 (0.17) and 1.90 (0.12), respectively, in growing tumors. The T/Np and T/Nm differed significantly between the two groups (T/Np, P < .001; T/Nm, P < .001). Receiver operating characteristic curve analysis showed that cutoffs of 1.56 and 1.76 for T/Np (93.33% sensitivity, 75.00% specificity) and T/Nm (100.00% sensitivity, 93.75% specificity), respectively, could be used to diagnose a growth rate of >100 mm³ /year. The area under the curve was 0.85 (95% confidence interval, 0.70-1.00) for T/Np and 0.94 (0.82-1.00) for T/Nm.

CONCLUSION

Growing VSs show higher signal intensities on Gd-enhanced MRI. Thus, measuring the signal intensity of VS on Gd-enhanced MRI may aid in predicting VS growth.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Exteriorization of Petrous Bone Cholesteatoma by Endonasal Endoscopic Approach: A Case Report

A 61-year-old woman presented with diplopia and headache. The patient had a longstanding history of petrous bone cholesteatoma (PBC) on the left side and had undergone multiple surgeries to address it. Computed tomography (CT) revealed a radiolucent lesion with bony destruction in the left petrous apex. Magnetic resonance imaging of the lesion revealed a hypointense area on T1-weighted images and a hyperintense area on T2-weighted and abnormal diffusion-weighted images. A diagnosis of recurrent petrous apex cholesteatoma was made. The patient was treated by exteriorization using an endoscopic endonasal approach. The patient is in remission and doing well. The ideal treatment of PBC is complete excision, though exteriorization using an endoscopic endonasal approach is considered a second option when excision is not possible.

Prognostic significance of inflammatory response markers for locally advanced squamous cell carcinoma of the external auditory canal and middle ear

We investigated the prognostic significance and treatment outcomes of pretreatment inflammatory response markers for locally advanced squamous cell carcinoma (SCC) of the external auditory canal (EAC) and middle ear (ME). Between July 2003 and July 2019, 21 patients with SCC of the EAC (n = 18) or ME (n = 3) who received radiotherapy with or without surgery or systemic therapy (radiotherapy alone [n = 2], radiotherapy + systemic therapy [n = 6], radiotherapy + surgery [n = 7], radiotherapy + surgery + systemic therapy [n = 6]) were retrospectively examined. The median radiation dose was 66.0 (range, 50.4-70.0) Gy, with daily fractions of 1.8-2.0 Gy. The median follow-up period was 25 months (range, 6-137). The two-year overall survival (OS), progression-free survival (PFS), and locoregional control (LC) rates were 61%, 48%, and 55%, respectively. OS, PFS, and LC did not differ significantly according to patient- (age, sex), tumor- (Pittsburgh stage, pretreatment neurological findings), and treatment-related (surgery or systemic therapy, radiation dose, prophylactic neck irradiation) factors. Conversely, there were significant differences in OS, PFS, and LC between patients with high and low pretreatment C-reactive protein-to-albumin ratios (p = 0.002, 0.003, and 0.004, respectively). OS also differed significantly between patients with high and low pretreatment neutrophil-to-lymphocyte ratios (NLR; p = 0.037). Other inflammatory response markers, including platelet-to-lymphocyte ratio (PLR) and albumin-to-globulin ratio (AGR), did not influence OS, PFS, or LC. Our findings suggest that pretreatment C-reactive protein-to-albumin ratio and NLRs have a significant impact on treatment outcomes in patients with locally advanced SCC of the EAC and ME.

Dietary intake of vegetables, fruit, and antioxidants and risk of ulcerative colitis: A case-control study in Japan

OBJECTIVES

Oxidative stress is considered one of the etiologic factors involved in ulcerative colitis (UC), yet there is limited epidemiologic information regarding the relationship between antioxidant intake and the risk of UC. The aim of the present case-control study in Japan was to examine the association between intake of green and yellow vegetables, other vegetables, fruit, vitamin C, vitamin E, retinol, alpha-carotene, beta-carotene, and cryptoxanthin and UC risk.

METHODS

A total of 384 cases within 4 y of diagnosis with UC and 665 controls were included in the study. Data on dietary intake and confounders were obtained using a self-reported questionnaire. Information on dietary factors was collected using a 169-item semiquantitative food-frequency questionnaire. Adjustment was made for sex, age, pack-y of smoking, alcohol consumption, history of appendicitis, family history of UC, education level, and body mass index.

RESULTS

Higher intake levels of other vegetables, vitamin C, and retinol were independently associated with a reduced risk of UC. The adjusted odds ratio between extreme quartiles was 0.51 (95% confidence interval [CI], 0.34-0.76; P for trend ≤ 0.001) for other vegetables, 0.45 (95% CI, 0.30-0.69, P for trend ≤ 0.001) for vitamin C, and 0.64 (95% CI, 0.43-0.95, P for trend = 0.04) for retinol. There were no associations between intake of green and yellow vegetables, fruit, vitamin E, alpha-carotene, beta-carotene, or cryptoxanthin and UC risk (P for trend = 0.29, 0.56, 0.89, 0.20, 0.69, and 0.22, respectively).

CONCLUSIONS

Intake of other vegetables, vitamin C, and retinol was inversely associated with UC risk.

Verbalization, Categorization, and Evaluation of Fundamental Surgical Skills: An Expert Consensus in Open Head and Neck Surgery

Objective

This study aimed to verbalize fundamental surgical skills required for open head and neck surgery (OHNS), to organize them by categorization, and to establish a consensus among surgeons regarding the importance and difficulty of each skill.

Summary Background Data

Improvement of fundamental surgical skills is the core of surgical education; however, surgical skills are not yet organized, and consensus in any surgical field remains uncertain.

Methods

Fundamental surgical skills during OHNS were collected from surgical textbooks, real surgeries, and expert interviews. The items were analyzed to calculate the frequency of words and were categorized by 2 expert surgeons. After consensus on the importance and difficulty of each item was established by 15 expert surgeons using a Delphi survey, principal component (PC) analysis was performed to integrate importance and difficulty into a single parameter.

Results

Sixty skills were verbalized and categorized into 7 categories: "skin flap elevation (n = 6)," "vessel management (n = 9)," "nerve preservation (n = 8)," "instrument handling (n = 11)," "counter traction (n = 7)," "tissue exposure (n = 9)," and "flow and planning (n = 10)." In the Delphi survey, expert consensus was established after 2 voting rounds (Cronbach's α ≥ 0.80). The "counter traction" and "flow and planning" categories had high PC scores, which indicate priority in surgical education.

Conclusion

Fundamental OHNS skills were verbalized, categorized, and evaluated via expert consensus. Assessment of surgeons' skills by the structured items hereby developed will help standardize the quality of OHNS and improve patient outcomes.

Case-specific three-dimensional hologram with a mixed reality technique for tumor resection in otolaryngology

OBJECTIVE

We report our first experience of using a case-specific three-dimensional (3D) hologram for tumor resection in otolaryngology to show the proof of concept. In addition, a questionnaire was administered to assess the usefulness of the mixed reality technique in otolaryngology.

METHODS

A case-specific 3D hologram was developed from enhanced images of dynamic computed tomography, with reference to contrast-enhanced magnetic resonance images, and used for preoperative planning and intraoperative image reference. To evaluate the usefulness of the 3D hologram with head mount displays (HMDs), 18 attendings and resident otolaryngologists completed a questionnaire with the Likert scale.

RESULTS

The case-specific 3D hologram on HMDs was successfully used by means of easy gesture-handling without any monitors preoperatively and intraoperatively. The experience of picturing the tumor localization and evaluating the surgical approach was statistically better using the 3D hologram on HMDs than using the computer images (P < .01). Similarly, the holograms were observed to be better for intraoperative application and surgical education than computer images (P < .01).

CONCLUSION

We demonstrated the use of a case-specific 3D hologram for tumor resection in otolaryngology. The technology may be useful for preoperative planning and intraoperative image reference, especially for challenging cases, and surgical education.

LEVEL OF EVIDENCE

NA.

Association of the prognosis and severity of idiopathic sudden sensorineural hearing loss with cervical ultrasonographic findings

OBJECTIVE

The aim of this study was to investigate the association of the prognosis and severity of idiopathic sudden sensorineural hearing loss (ISSNHL) with cervical ultrasonographic findings suggestive of cardiovascular risk.

METHODS

Seventy-four inpatients with ISSNHL were included in our study. Cervical ultrasonography was performed to evaluate the common carotid artery (CCA), internal carotid artery (ICA), and vertebral artery (VA). The peak systolic velocity, end diastolic velocity, intima-media thickness, pulsatility index (PI), and resistance index (RI) were evaluated. We investigated the relationship of these variables with the severity and prognosis of ISSNHL.

RESULTS

ICA-PI, ICA-RI, and CCA-RI were significantly higher in patients with poor hearing prognosis than in those with good prognosis. The variables of VA were not related to the prognosis of ISSNHL. There were no statistically significant differences between ISSNHL severity and cervical ultrasonographic findings.

CONCLUSIONS

We found that PI and RI might be prognostic factors for ISSNHL.

Development and validation of an iPad-based Japanese language monosyllable speech perception test (iCI2004 monosyllable)

BACKGROUND

Speech perception tests are commonly used as indices reflecting hearing ability in daily life. In Japan, the CI-2004 test, first developed in 2004, is widely used as standard, but it was not validated against a large number of normal hearing controls and hearing loss patients.

AIMS/OBJECTIVES

The primary objective of the present study was to develop and validate iPad-based software for the Japanese monosyllable speech perception test, 'iCI2004'.

MATERIAL AND METHODS

Seven universities and two medical centers participated in this study. The hearing threshold and Japanese monosyllable speech perception test results of 77 people with normal hearing and 459 people with hearing loss were collected.

RESULTS

All participants with normal hearing achieved almost perfect perception results both in quiet and in noise. For cochlear implant users, the average monosyllable speech perception score was 55.1 ± 19.6% in quiet and 40.3 ± 19.2% in noise (SNR + 10dB).

CONCLUSIONS AND SIGNIFICANCE

We developed iPad-based Japanese monosyllable speech perception test software and validated it by testing a large number of controls and hearing loss patients with cochlear implants or hearing aids. The developed monosyllable speech perception test has a sufficiently large dynamic range for assessing improvement in speech perception in Japanese cochlear implant users.

The association between ear involvement and clinical features and prognosis in ANCA-associated vasculitis

OBJECTIVE

The concept of otitis media with ANCA-associated vasculitis (OMAAV) was recently proposed by the study group of the Japan Otological Society. However, little is known about the effect of ear involvement on the clinical features and prognosis of AAV. We investigate this issue in this study.

METHODS

We retrospectively examined 36 patients diagnosed with OMAAV and 44 patients diagnosed with AAV without ear involvement (non-OMAAV) at Ehime University Hospital from 2013 to 2018. We collected serological findings including ANCA type and titer, C-reactive protein (CRP), serum creatinine level, organ involved at initial diagnosis, treatment, remission, disease relapse, and mortality from medical records. We investigated whether clinical features and outcomes differed between the OMAAV and non-OMAAV groups.

RESULTS

Age, ANCA titer, and CRP at initial diagnosis were not significantly different between the two groups, and the rate of intravenous cyclophosphamide (IVCY) use also did not differ. The proportions of patients with concurrent eye involvement, facial palsy (FP), and hypertrophic pachymeningitis (HCP) were significantly higher in the OMAAV than in the non-OMAAV group (p = 0.005, 0.005 and 0.049, respectively), while both renal and peripheral nerve involvement were significantly less common in OMAAV patients (p = 0.04). Among the 30 patients with renal involvement, serum creatinine level at diagnosis was significantly lower in the OMAAV group (p = 0.04). The mortality rate was 8.3% in OMAAV and 6.8% in non-OMAAV cases, but this difference was not significant. The rate of relapse was 33.3% in OMAAV and 13.6% in non-OMAAV cases; this difference was significant (p = 0.04).

CONCLUSIONS

Serological measurements of disease activity did not differ between the groups. Eye involvement, FP, and HCP, however, were significantly more common in AAV with ear involvement. In addition, renal involvement was less common and renal impairment was milder in AAV with ear involvement. These findings can be considered clinical features. The relapse rate was significantly higher in AAV with ear involvement.

Pathological evaluation of tumor grade for salivary adenoid cystic carcinoma: A proposal of an objective grading system

Three pathological grading systems advocated by Perzin/Szanto, Spiro, and van Weert are currently used for adenoid cystic carcinoma (AdCC). In these systems, the amount or presence of the solid tumor component in AdCC specimens is an important index. However, the “solid tumor component” has not been well defined. Salivary AdCC cases (N = 195) were collected after a central pathology review. We introduced a novel criterion for solid tumor component, minAmax (minor axis maximum). The largest solid tumor nest in each AdCC case was histologically screened, the maximum oval fitting the solid nest was estimated, and the length of the minor axis of the oval (minAmax) was measured. The prognostic cutoff for the minAmax was determined using training and validation cohorts. All cases were evaluated for the four grading systems, and their prognostic impact and interobserver variability were examined. The cutoff value for the minAmax was set at 0.20 mm. Multivariate prognostic analyses showed the minAmax and van Weert systems to be independent prognostic tools for overall, disease‐free, and distant metastasis‐free survival while the Perzin/Szanto and Spiro systems were selected for overall survival but not for disease‐free or distant metastasis‐free survival. The highest hazard ratio for overall survival (11.9) was obtained with the minAmax system. The reproducibility of the minAmax system (kappa coefficient of 0.81) was scored as very good while those of the other three systems were scored as moderate. In conclusion, the minAmax is a simple, objective, and highly reproducible grading system useful for prognostic stratification for salivary AdCC.

The hearing prognosis of otitis media with ANCA-associated vasculitis

OBJECTIVE

The concept of otitis media with ANCA-associated vasculitis (OMAAV) was recently proposed by the study group of the Japan Otological Society. However, information remains limited regarding the hearing outcome of OMAAV. Thus, we investigated this issue in this study.

METHODS

We retrospectively examined 50 ears from 32 patients diagnosed with OMAAV at our hospital between 2010 and 2019. We collected the results of pure tone audiometry (PTA) at diagnosis and changes in PTA threshold after treatment, serological findings including ANCA type, titer, soluble interleukin-2 receptor (sIL2R), and C-reactive protein, organs involved at initial diagnosis, treatment, and disease relapse from medical records. According to the hearing outcome, patients were divided into two groups: good prognosis and poor prognosis groups. We investigated the clinical features, treatment, and changes in PTA between the groups.

RESULTS

Age, sex, ANCA negativity, and the use of intravenous cyclophosphamide (IVCY) were significantly related to hearing prognosis of OMAAV, while other organs involved at diagnosis, serological findings, and relapse rate were not significantly associated with hearing outcome. Hearing level at diagnosis was significantly better in good prognosis group, while air-bone gap (ABG) was not significantly different between the groups. The air conduction (AC), bone conduction (BC), and ABG were significantly improved in the good prognosis group. However, ABG was not improved in the poor prognosis group, while AC and BC were significantly improved. The AC hearing level at diagnosis (58.5 dB) and hearing gain at 2 weeks after treatment (12.5 dB) were suggested as good indicators for predicting the hearing outcome of OMAAV.

CONCLUSION

Younger age, male sex, shorter period from onset to diagnosis, the use of IVCY, and better hearing threshold at diagnosis were the good prognostic factors of the hearing outcome of OMAAV. These results suggest that earlier diagnosis of OMAAV might be needed for better hearing outcome, and the use of IVCY may be recommended for the treatment of OMAAV patients.

Low-Normal Platelets and Decreasing Platelets Are Risk Factors for Hearing Impairment Development

OBJECTIVE

Identification of undefined risk factors will be crucial for the development of therapeutic strategies in hearing impairment. Platelets are likely to affect the development of sudden sensorineural hearing loss, which is a primary risk factor for permanent hearing impairment. This implies that abnormal platelets might contribute to long-term hearing loss. This study investigated the role of platelets in the development of hearing impairment over a 5-year period.

METHODS

This study was a retrospective cohort study and consisted of a population-based survey, which was performed for 1,897 participants in 2014 to 2019. To evaluate the effect of platelet level on hearing ability, the subjects were divided into two groups: a high-normal platelet group (25 ∼ 40 × 10⁴ cells/μL) and a low-normal platelet group (15 ∼ 25 × 10⁴ cells/μL). Subjects were defined as having hearing impairment when pure tone audiometry was over 25 dB HL in either ear (tested in 2017 and 2019). Incidence of hearing impairment was analyzed.

RESULTS

Incidence of hearing impairment at low frequencies was significantly higher in the low-normal platelet group than in the high-normal group year over year. Low-normal platelet count associated with low-frequency hearing impairment (LFHI) incidence (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.15-4.76). In the low-normal platelet group, subjects whose counts declined from baseline developed more LFHI than those whose counts increased over time. Further, decreasing platelets appeared to be an independent risk factor contributing to the incidence of LFHI (OR, 2.10; 95%CI, 1.09-4.06) in the low-normal platelet group.

CONCLUSION

Both a low-normal platelet and a declining platelet count were independently associated with the incidence of LFHI.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1287-E1295, 2021.

Non-recovery animal model of severe facial paralysis induced by freezing the facial canal

OBJECTIVE

Some cases of peripheral facial paralysis are resistant to treatment, thus, a non-recovery model of facial paralysis is needed to develop new treatment strategies for this condition. The purpose of the current study was to develop an animal model of which facial palsy was severe and prolonged.

METHODS

Ten 8-week-old female Hartley guinea pigs weighing between 400 and 500 g were used for the animal model. The vertical segment of the facial canal was accessed via the otic bulla, without removing the bony wall of the facial canal. The canal was then frozen for 5 s using freeze spray. Facial movements, electroneurography (ENoG), histology, and changes in temperature were evaluated.

RESULTS

All animals exhibited complete facial paralysis immediately after the procedure and recovered gradually, however, not all of them had recovered completely 15 weeks after freezing. The ENoG values one week after freezing for all animals (10/10) were 0%. Histological examination one week after freezing revealed that most of the vertically placed myelinated nerve fibers which had been frozen were remarkably affected and denatured. The number of vertically placed myelinated nerve fibers increased 15 weeks after freezing, but the nerve fibers were smaller than normal nerve fibers and were distorted in shape.

CONCLUSION

Complete facial paralysis was induced in Hartley guinea pigs by freezing the facial canal. The behavioral, ENoG, and histopathological data suggest that the facial paralysis was severe and prolonged. This model may assist in developing novel treatment for severe facial palsy and facilitate basic research on facial nerve regeneration.

The impact of clinicopathological factors on clinical outcomes in patients with salivary gland adenoid cystic carcinoma: a multi-institutional analysis in Japan

BACKGROUND

Owing to the low incidence of adenoid cystic carcinoma (AdCC), reliable survival estimates and prognostic factors remained unclarified.

METHODS

In this multi-institutional retrospective analysis, we collected 192 AdCC cases, and investigated the impact of clinicopathological factors on clinical outcomes of the patients. All AdCC cases were of salivary gland origin and were surgically treated with curative intent. Diagnoses of AdCC were validated by a central pathology review by expert pathologists.

RESULTS

The 5-year overall survival (OS) and disease-free survival (DFS) rates were 92.5 and 50.0%, respectively. Treatment failure occurred in 89 patients (46%) with the distant failures in 65 (34%). Multivariate analysis indicated that pN2 and a pathologically positive surgical margin were independent prognostic factors for both OS and DFS. Histological grade III was an independent prognostic factor for OS. A primary site in the submandibular gland, pT3/4, pN1, and histological grade II were independent prognostic factors for DFS. Postoperative radiation therapy (PORT) improved the locoregional control (LRC) rate. Prophylactic neck dissection was not associated with a better OS or better LRC among patients with cN0. Facial nerve dissection did not improve clinical outcomes in parotid AdCC cases without facial nerve palsy.

CONCLUSIONS

A higher TN classification, a pathologically positive surgical margin, and a higher histological grade were associated with a lower OS. PORT improved LRC rates but neck dissection failed to improve clinical outcomes in patients with cN0. As the distant metastasis was frequent, effective systemic therapy is imperative to improve the survival of AdCC patients.

Association between hypertension, dyslipidemia, and diabetes and prevalence of hearing impairment in Japan

Epidemiological information regarding the relationship between hypertension, dyslipidemia, and/or diabetes and hearing impairment (HI) has been controversial. The present cross-sectional study investigated this issue in Japan. The subjects were 371 men and 639 women aged 36‒84 years. Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or current use of antihypertensive medication. Dyslipidemia was defined as a serum low-density lipoprotein cholesterol concentration ≥140 mg/dL, high-density lipoprotein cholesterol concentration <40 mg/dL, triglyceride concentration ≥150 mg/dL, or current use of cholesterol-lowering medication. Diabetes was defined as a fasting plasma glucose level ≥126 mg/dL, hemoglobin A1c level ≥6.5%, or current use of diabetic medication. HI was defined as present when subjects did not respond to a pure-tone average of >25 dB HL in the better hearing ear. Adjustments were made for age, smoking, alcohol consumption, body mass index, household income, and education. The prevalence of HI was 31.5% in men and 20.8% in women. In men, hypertension, but not dyslipidemia or diabetes, was independently positively associated with HI: the adjusted prevalence ratio (PR) was 1.52 (95% CI: 1.07‒2.16). Having at least two cardiovascular risk factors among hypertension, dyslipidemia, and diabetes was independently positively related to HI: the adjusted PR was 1.82 (95% CI: 1.11‒2.99, P for trend = 0.02). Such positive associations were not found in women. Hypertension and having at least two cardiovascular risk factors may be positively associated with HI in men only.

Evaluation of the structure of the otoconial layer using micro-computed tomography

OBJECTIVE

Estrogen deficiency caused by bilateral ovariectomy (OVX) has been reported to lead to morphological changes in otoconia. Thus, we examined the morphological changes in the otoconial layer after OVX. We also investigated whether micro-computed tomography (µCT) is useful for the detection of morphological changes in the otoconial layer.

METHODS

The otic capsules of C57BL/6 J mice were removed and evaluated using histological techniques and µCT at 2, 4, and 8 weeks after OVX or sham surgery. The volume of the utricle otoconial layer was measured and compared between the OVX and sham groups. The µCT scan and histological study results were also compared.

RESULTS

The volume of the utricle otoconial layer was significantly increased 4 weeks after OVX compared to the sham group in both histological and µCT studies (p < 0.05). The volume of the otoconial layer measured using µCT was significantly correlated with the histological study results (p < 0.05).

CONCLUSION

The volume of the utricle otoconial layer increased after OVX. These morphological changes could be detected by µCT.

Central pathology review of salivary gland adenoid cystic carcinoma

BACKGROUND

To assess the role of a central pathology review in the diagnosis of salivary gland adenoid cystic carcinoma (AdCC).

METHODS

Surgically resected salivary gland tumors diagnosed as AdCC (n = 219) in 15 reference hospitals in Japan were subjected to a retrospective pathological re-evaluation.

RESULTS

After the review, the AdCC diagnosis was revised in 21/219 cases (9.6%). The six benign tumors (2.7%) comprised five basal cell adenomas and one pleomorphic adenoma, and among these six patients, three received postoperative radiotherapy. The remaining 15 malignant tumors (6.8%) comprised nine basal cell adenocarcinomas and six other carcinomas. All revised basal cell adenoma/adenocarcinoma cases were of rare cribriform variants.

CONCLUSIONS

A significant proportion of AdCC pathology reports were revised after the central pathology review. It should be emphasized that the greatest attention should be paid in differentiating AdCC from cribriform variant basal cell adenoma/adenocarcinoma, which is very rare in salivary gland tumors.

Development of proficiency-based knot-tying and suturing curriculum for otolaryngology residents: A pilot study

OBJECTIVE

Basic surgical skills such as knot-tying and suturing are important for all otolaryngologists, regardless of subspecialty. The present study was undertaken in order to assess basic surgical techniques such as knot-tying and suturing required for novice otolaryngology residents with taking the variety of subspecialties into consideration, and evaluate the impact of a proficiency-based training curriculum based on these techniques.

METHODS

A prospective study was performed for developing of proficiency-based knot-tying and suturing curriculum for otolaryngology residents in the third post-graduate year (PGY-3). The proficiency-based training curriculum was developed based on the tasks selected by RAND/UCLA method with expert panel, which is an iterative and anonymous survey used to establish consensus among participants. Expert panelists were selected from various divisions to reflect variety of their subspecialties. PGY-3 residents trained with the developed curriculum that included proctored pre-test, self-training to proficiency, and proctored post-test. Visual analogue scale (VAS) of trainees' overall competence in the operating room was self-assessed by each resident, before and after completing the training curriculum.

RESULTS

Nine PGY-3 residents were enrolled as trainees. Eleven experts chosen as panelists had various subspecialty, including 2 from otology, 2 from rhinology, 2 from laryngology, 2 from head and neck surgery, and 3 from general otolaryngology. Seven tasks were selected from RAND/UCLA method and used to develop the curriculum. Trainee scores at pre-test were significantly lower than expert scores for all 7 tasks (p < 0.01) and each coefficient of variation of trainee score was larger than that of expert score (p < 0.05), supporting construct validity. The mean of composite scores between pre-test and post-test had statistical significance (68.6 ± 11.6 vs 95.9 ± 3.6, p < 0.01), documenting substantial improvement after training. Self-assessment VAS was also improved pre- to post-training (1.2 ± 0.9 vs 4.5 ± 1.4, p < 0.01). A follow-up questionnaire showed that trainees felt the educational curriculum to be beneficial.

CONCLUSION

In the present study, seven basic technical skills were selected using the RAND/UCLA method and used to create a proficiency-based training curriculum. Our results indicate that this curriculum significantly improves proficiency of basic surgical skills of junior otolaryngology residents.

Intractable Otitis Media Presenting as Falsely Positive for Proteinase 3-ANCA: A Case Report

Herein, we report a case of otitis media caused by methicillin-resistant Staphylococcus aureus (MRSA), presenting as falsely positive for proteinase 3 (PR3)-antineutrophil cytoplasmic antibodies (ANCA). A 47-year-old woman was referred to our hospital with a complaint of left otorrhea. An otorrhea culture yielded MRSA, and the patient was treated using tympanoplasty. Postoperative administration of teicoplanin lead to drug-induced neutropenia and was discontinued 4 days after the operation. One month after the operation, the patient's otorrhea recurred, and it was accompanied by hearing impairment. The otorrhea culture yielded MRSA again, while serum was positive for PR3-ANCA (6.8 U/mL). As MRSA was detected in the patient's otorrhea sample, she was treated with linezolid. Her symptoms then improved immediately. Although the PR3-ANCA positivity remained, the patient's otorrhea and hearing impairment had not recurred for 3 years when this report was submitted. Therefore, we conclude that this is a case of false PR3-ANCA positivity.

Elevated exosomal lysyl oxidase like 2 is a potential biomarker for head and neck squamous cell carcinoma

OBJECTIVES

The secretory enzyme lysyl oxidase like 2 (LOXL2) is speculated to contribute to tumor progression through its functions in the remodeling of extracellular matrix and epithelial-mesenchymal transition. We previously identified elevated expression of LOXL2 in metastatic human head and neck squamous cell carcinoma (HNSCC) cells in a mouse lymph node metastases model. Here we performed a case series study examining LOXL2 expression levels in human serum from HNSCC patients to evaluate whether LOXL2 is worth evaluation in a large cohort study.

METHODS

LOXL2 protein levels in three serum samples from HNSCC patients were assessed by immunoblotting and LOXL2 tissue expression was examined in one human tongue squamous cell carcinoma (SCC) tissue by immunohistochemistry as a representative of HNSCC tissue. Serum samples were further fractionated in exosomes and supernatants by ultracentrifugation, which were then subjected to immunoblot and in vitro LOX activity analyses. Exosomal LOXL2 levels of 36 serum samples from HNSCC patients and seven healthy volunteers were measured using polymer sedimentation exosome preparation followed by ELISA measurement and subjected to statistical analyses.

RESULTS

Immunoblot analyses revealed that LOXL2 was present in serum exosomal fractions from three HNSCC patients, and we observed approximately threefold higher levels of LOXL2 in HNSCC patients compared with three healthy volunteers. Immunohistochemical LOXL2 staining was detected in HNSCC cells in addition to non-cancerous lipid tissues and some muscles in human tongue HNSCC tissue. Further measurements of exosomal LOXL2 by ELISA showed over ninefold higher mean LOXL2 levels in patients compared with controls. Statistical analysis revealed a correlation between elevated serum exosomal LOXL2 levels and low-grade, but not high-grade, HNSCC.

CONCLUSIONS

Our case series study that elevated serum exosomal LOXL2 levels exhibited a correlation with low-grade HNSCCs. A follow-up large cohort clinical study will be required to determine the potential clinical utility of LOXL2 as a new biomarker and/or therapy target for HNSCCs.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E327-E334, 2020.