Chronic Nasal Obstruction Causes Daytime Sleepiness and Decreased Quality of Life Even in the Absence of Snoring

Background

There has been a growing awareness that nasal obstruction may impair various daily and social activities. We performed a questionnaire survey in a working population to clarify the contribution made by snoring concomitant with nasal obstruction to daytime sleepiness and quality of life (QOL).

Methods

Seven thousand nine hundred eighty daytime workers were asked to complete questionnaires, 7702 responded, and the data from 3442 subjects were finally analyzed. Nasal obstruction and snoring were graded into three and four categories, respectively. Daytime sleepiness and QOL were assessed by the Epworth Sleepiness Scale (ESS) and the Medical Outcomes Study 36-Item Short-Form Health Survey, respectively.

Results

Subjects with chronic nasal obstruction, even if snoring was absent, reported significantly higher ESS scores and lower QOL scores than control subjects, and the presence of habitual snoring had an additive influence on these changes. The ESS and mental QOL scores adjusted for age, sex, and body mass index showed the same tendency.

Conclusion

Induction of sleep-disordered breathing (SDB) is a possible cause of excessive daytime sleepiness and impaired QOL in subjects with nasal obstruction. A variant of SDB such as silent upper respiratory resistance syndrome may participate in this phenomenon in the absence of snoring.

Relationships between nasal obstruction, observed apnea, and daytime sleepiness

Objective

We administered a questionnaire survey to a working population in an attempt to clarify the relationships between self-reported nasal obstruction, observed apnea during sleep, and daytime sleepiness.

Study Design

A total of 7980 daytime workers were asked to complete questionnaires about nasal obstruction, apnea during sleep, and daytime sleepiness. Of the 7702 responses, the data from 4818 subjects were analyzed. Nasal obstruction and observed apnea were graded into 3 categories. Daytime sleepiness was assessed by the Epworth Sleepiness Scale.

Results

Subjects with chronic nasal obstruction had 5.22 and 2.17 times higher odds for having habitual observed apnea and excessive daytime sleepiness (EDS), respectively, compared with those without nasal obstruction ( P < 0.001). After adjusting for 3 potential confounding factors (age, sex, and body mass index) and the presence of habitual observed apnea, odds ratios for having EDS decreased, but still remained significant.

Conclusion

Nasal obstruction is likely to cause daytime sleepiness, at least in part, by causing sleep-disordered breathing including apnea during sleep.

Nasopharyngeal Streptococcus pneumoniae carriage in Japanese children attending day-care centers

OBJECTIVES

We conducted a prospective bacteriological survey to investigate antibiotic resistance-related genetic characteristics and the turnover of nasopharyngeal Streptococcus pneumoniae carriage in healthy children in day-care centers (DCCs).

METHODS

A total of 363 nasopharyngeal mucus samples were collected from children aged 0 to 6 years attending two DCCs in the summer of 2004 (n=181) and the following winter (n=182). We obtained 157 S. pneumoniae isolates and analyzed them by antibiotic susceptibility testing, PCR assay for the penicillin-binding protein (PBP) genes and macrolide-resistance gene, and pulsed-field gel electrophoresis (PFGE).

RESULTS

The overall carriage rate was 43.3% (157/363). The percentages of penicillin-intermediately resistant S. pneumoniae (PISP) strains, penicillin-resistant S. pneumoniae (PRSP) strains, erythromycin-intermediately resistant S. pneumoniae strains and erythromycin-resistant S. pneumoniae strains were 35.7% (56/157), 0.6% (1/157), 1.9% (3/157), and 69.4% (109/157), respectively. The percentages of S. pneumoniae strains with the pbp mutation(s) and mefA and/or ermB gene(s) were 92.4% (145/157) and 71.3% (112/157), respectively. Fifty strains with different PFGE patterns were obtained from among the 157 isolates. Thirteen strains were observed in both seasons, but only one of these strains was isolated from the same carrier. Twenty-one strains (42.0%) were isolated from two or more children, and 17 of these were each isolated from children attending the same DCC.

CONCLUSIONS

These results indicate the spread of S. pneumoniae, particularly those with antibiotic-resistance genes, and the vigorous genetic turnover and substantial horizontal transmission of this pathogen in healthy children attending DCCs in Japan.

Immunoreactivities for glutathione S-transferases and glutathione peroxidase in the lateral wall of pigmented and albino guinea pig cochlea

Dark-skinned people are known to be more tolerant of ototraumatic noise than are light-skinned people, and pigmented animals are more tolerant of ototraumatic noise and aminoglycoside ototoxicity than are albino animals. Such tolerance may be dependent on the local ability of detoxification and antioxidant enzymes, including glutathione S-transferase (GST) and glutathione peroxidase (GSPx). In the present study, we examined the difference in GST/GSPx expression in the lateral wall of the cochlea between pigmented and albino guinea pigs. Eight-week-old male pigmented and albino guinea pigs were killed by transcardiac perfusion with 2% paraformaldehyde. The cochlear ducts were isolated, further fixed with 4% paraformaldehyde, decalcified, and then embedded in paraffin. Sections prepared at 5-microm thickness were incubated with anti-GST-alpha,-mu,-pi, or anti-GSPx antibody, reacted with Alexa Fluorconjugated secondary antibody, and examined under a Carl Zeiss Axioskop 2 plus fluorescence microscope. The cochlea ducts were also subjected to immunoelectron microscopy for GST-pi by the postembedment method. The stria vascularis of pigmented guinea pigs was strongly immunoreactive for GST-alpha,-mu,-pi, and GSPx, whereas no or only weak immunoreactivities were seen in the stria vascularis of albino guinea pigs. The spiral ligament showed positive but different immunoreactivities for these enzymes between the strains. Double-stained immunofluorescence micrographs for GST-pi and GSPx showed a close resemblance of localization between the two enzymes in both pigmented and albino guinea pigs. At the ultrastructural level, immunoreactivity for GST-pi was localized preferentially in the melanin cells of pigmented guinea pigs. These results suggest that correlation between pigmentation and inner ear susceptibility is, at least partially, attributed to the different distribution of GST/GSPx in the stria vascularis.

Prostaglandin E1 versus steroid in combination with hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss

OBJECTIVE

We conducted a controlled retrospective analysis of patients with idiopathic sudden sensorineural hearing loss (ISSNHL) in order to investigate the effect of prostaglandin E1 (PGE1) plus hyperbaric oxygen (HBO) therapy in comparison with that of steroid plus HBO therapy.

METHODS

One hundred and ninety-six consecutive patients with ISSNHL (hearing levels > or ==40dB; time from the onset of hearing loss to the start of treatment < or ==30 days) were enrolled. Ninety-five patients underwent PGE1 plus HBO therapy (PG group) and 101 underwent steroid administration plus HBO therapy (steroid group). Hearing recovery was evaluated by grade assessment and by the improvement in hearing compared to the unaffected contralateral ear.

RESULTS

The hearing levels after treatment were 52.2+/-3.0 and 47.5+/-2.8dB, the hearing gains were 31.3+/-2.2 and 27.2+/-2.3dB, the cure rates were 28.4% and 28.7%, the recovery rates were 54.7% and 53.5%, and the hearing improvement rates were 48.4+/-5.1% and 53.9+/-4.2% in the PG and steroid groups, respectively. There were no significant differences between the two groups.

CONCLUSION

We concluded that PGE1 and a steroid are equally effective in the treatment of ISSNHL when used together with HBO therapy. PGE1 plus HBO therapy can be one of the potential alternative treatments for ISSNHL, particularly in steroid-intolerant patients such as those with severe diabetes mellitus, an active peptic ulcer, or viral hepatitis.

Prostaglandin E1 in combination with hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss

CONCLUSIONS

Prostaglandin E1 (PGE1) is less effective than stellate ganglion block (SGB) in the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) patients with severe hearing losses when used together with hyperbaric oxygen (HBO) therapy. In contrast with the systemic action of intravenous PGE1, SGB's localized vasodilating action may explain its advantage over intravenous PGE1.

OBJECTIVES

To investigate the effect of PGE1 plus HBO therapy on ISSNHL in comparison with that of SGB plus HBO therapy.

PATIENTS AND METHODS

We retrospectively analyzed 205 consecutive patients with ISSNHL (hearing levels > or = 40 dB; time from the onset of hearing loss to the start of treatment < or = 30 days). Ninety-five patients underwent intravenous PGE1 plus HBO therapy (PG group) and 110 underwent SGB plus HBO therapy (SGB group). Hearing recovery was evaluated by grade assessment and by hearing improvement compared to that in the unaffected contralateral ear.

RESULTS

The overall hearing outcome was not statistically different between the two groups. For patients with initial hearing levels <80 dB, the groups had roughly equivalent hearing outcomes, whereas in patients with initial hearing levels > or = 80 dB, the hearing improvement rate was significantly higher in the SGB group than in the PG group (53.0 +/- 5.0% vs 35.3 +/- 6.8%; p <0.05).

[Clinical study of early laryngeal cancer]

We retrospectively analyzed 71 consecutive cases of early laryngeal cancer (stage I or II) that had undergone primary treatment in our department between 1999 and 2004. There were 68 males and 3 females, and their ages ranged from 40 to 85 years of age (average; 67.7 years). Eight patients had the supraglottic type, 61 had the glottic type, and 2 had the subglottic type. Chemoradiotherapy was performed as the primary treatment except in the patients with glottic T1a cancer, who received radiotherapy alone. The 5-year survival rates was 91.1% for glottic cancer (T1a: 100%, T1b: 92.3%, T2: 85.8%) and 75.0% for supraglottic cancer. The local control rate of glottic cancer was 79.6% (T1a: 80.0%, T1b: 74.0%, T2: 85.2%), and significantly higher than that of supraglottic cancer (56.2%, p < 0.05). The laryngeal preservation rate was 84.4% in glottic cancer (T1a: 100%, T1b: 76.9%, T2: 77.5%) and 58.3% in supraglottic cancer, and the difference between T1a and T2 glottic cancer was significant (p < 0.05). Local recurrence and cervical lymph node metastasis were seen in 9 patients and 6 patients, respectively. Distant metastasis occurred in 4 patients, all of whom had the glottic type. Four patients died of their disease, and distant metastasis was the major cause of death in 3 of them. These results indicate that additional treatment should be performed in cases in which radiotherapy/chemoradiotherapy is ineffective and that both in the early stages glottic and supraglottic cancers can be successfully treated by radiotherapy/chemoradiotherapy. The results also suggested that the survival of patients with early laryngeal cancer depends on whether they develop distant metastasis. Introduction of adjuvant chemotherapy to improve their prognosis remains to be assessed.

[Evaluation of quality of life in patients with allergic rhinitis]

Nasal symptoms of allergic rhinitis, such as watery rhinorrhea, sneezing and nasal obstruction, are thought to result in reduction in quality of life (QOL). In this study, we evaluated the QOL scores of patients suffering from allergic rhinitis, using the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and the Short Form-36 (SF-36). One hundred twenty six patients with allergic rhinitis who visited the department of otolaryngology of UOEH and affiliated hospitals from April, 2003 to March, 2004 were enrolled in this study. Each symptom of allergic rhinitis was shown to degrade the RQLQ scores. In particular, nasal obstruction and severity of the disease strongly related to the RQLQ scores. All the SF-36 scores of allergic rhinitis patients were lower than those of standard Japanese. Nasal obstruction was severer, and ocular symptoms were milder in the perennial group than in the seasonal group. The QOL scores of emotional aspects were significantly different between generations. The QOL score of social functioning increased, and that of mental health decreased with age. These results clearly indicate that nasal symptoms of allergic rhinitis cause degradation of QOL in daily and social lives. It would be interesting and necessary to evaluate QOL disturbance and loss of working efficiency in workers with allergic rhinitis in further studies.

Myxofibrosarcoma of the neck

We report a rare case of myxofibrosarcoma arising in the neck. A 55-year-old man presented with a two-year history of left-sided, painless, submandibular swelling. Computed tomography and magnetic resonance imaging (MRI) revealed an 80 x 35 mm, well defined, lobulated, submandibular tumour extending to the parapharyngeal space. The tumour showed uniformly low intensity and marked hyperintensity in T1- and T2-weighted MRI scans, respectively, and was scarcely enhanced by gadolinium. A tentative diagnosis of lymphangioma or plunging ranula was made, and the patient underwent local injection of OK-432, which proved to be ineffective. Resection of the tumour was then performed via a transcervical approach. The tumour was histopathologically and immunohistochemically diagnosed as a low-grade myxofibrosarcoma. The patient's post-operative clinical course was uneventful, and the patient was free of disease 27 months after surgery. The pathology, clinical characteristics and treatment of myxofibrosarcoma are bibliographically reviewed.

Eikenella corrodens in head and neck infections

BACKGROUND

Eikenella corrodens (E. corrodens) is a Gram-negative facultative anaerobic bacillus that originally was thought to be an attenuated and indigenous bacterium. In recent years, a number of reports have documented that E. corrodens can be a potential pathogen not only in immunocompromised patients but also in hosts with normal immunity. We herein study E. corrodens infections of the head and neck encountered in our department.

METHODS

Twenty-two consecutive patients treated in our department for E. corrodens infections of the head and neck were retrospectively analyzed. Microbial specimens were subjected to light microscopic examination, aerobic culture using chocolate and sheep blood agar media, and anaerobic culture using Brucella HK agar medium. Cultured bacteria were subjected to antimicrobial susceptibility tests by means of the broth microdilution method.

RESULTS

There were 16 males and 6 females with an average age of 29.9 years. Two patients had malignancy, while the other patients had no particular risk factors or underlying diseases. Infected sites were the ear in 6 cases, pharynx in 12 cases (tonsil in 10 cases), paranasal sinuses in 3 cases, and salivary gland in 1 case. Seventeen patients suffered polymicrobial infections. Staphylococcus and Streptococcus were the most frequently detected pathogens coexisting with E. corrodens, and mixed infections of E. corrodens and Streptococcus milleri group bacteria were prone to form abscesses. Isolated E. corrodens was susceptible to third-generation cephems (MIC90 = 0.15-0.25 microg/ml), carbapenems (MIC90 < or = 0.15 microg/ml), and new quinolones (MIC90 < or = 0.15 microg/ml), and resistant to oxacillin (MIC90 > 8 microg/ml), cefazolin (MIC90 > 4 microg/ml), macrolides (MIC90 = 4-8 microg/ml), and clindamycin (MIC90 > 4 microg/ml).

CONCLUSIONS

E. corrodens infections of the head and neck occur most frequently in the tonsil even in hosts with normal immunity. Coexistence with Streptococcus milleri group bacteria and the use of ineffective antibiotics can be exacerbating factors. First-choice drugs for E. corrodens infections should be third-generation cephems, carbapenems, or new quinolones.

Hyperbaric oxygen and steroid therapy for idiopathic sudden sensorineural hearing loss

In our controlled retrospective analysis of medical records in tertiary care academic medical center, we aimed to investigate the therapeutic effects of hyperbaric oxygen (HBO) therapy combined with steroid administration for idiopathic sudden sensorineural hearing loss (ISSNHL) in comparison with that of steroid administration alone. Our subjects were 130 consecutive inpatients with ISSNHL (hearing levels >/=40 dB; time from the onset of hearing loss to the start of treatment </=30 days). Sixty-seven patients underwent HBO plus steroid therapy (HBO group), and 63 were given steroids alone (steroid group). Hearing recovery was evaluated by grade assessment and by the improvement in hearing compared to that in the unaffected contralateral ear. The cure rate and hearing improvement rate were not statistically different between the two groups; however, the recovery rate was significantly higher in the HBO group than in the steroid group (59.7% vs. 39.7%; P < 0.05). With regard to patients with initial hearing levels of >/=80 dB, the hearing improvement rate was significantly higher in the HBO group than in the steroid group (51.1 +/- 7.0% vs. 27.1 +/- 7.8%; P < 0.05), while in patients whose initial hearing levels were <80 dB, hearing outcomes were not statistically different between the two groups. In both the HBO and steroid groups, patients with initial hearing levels of <80 dB showed a better hearing improvement rate than those with initial hearing levels of >/=80 dB. In conclusion HBO therapy shows a significant additional effect in combination with steroid therapy for ISSNHL, particularly in patients with severe hearing loss.

Oncocytic schneiderian papilloma confined to the sphenoid sinus detected by FDG-PET

We report a 55-year-old man with oncocytic schneiderian papilloma confined to the sphenoid sinus, which was initially detected by positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) at a very early stage. Based on CT and MRI findings, we suspected that the tumor was most likely benign; however, positive uptake in FDG-PET suggested malignancy. The patient underwent endoscopic resection of the tumor, and the histopathological diagnosis turned out to be oncocytic schneiderian papilloma. FDG-PET is thought to be a powerful tool to search for malignant lesions, but the present case demonstrates the fallibility of this technique. This should be taken into consideration when interpreting FDG-PET images.

Clinical features of head and neck cancer patients with methicillin-resistant Staphylococcus aureus

CONCLUSIONS

The risk factors for methicillin-resistant Staphylococcus aureus (MRSA) detection in head and neck cancer patients are the duration of hospitalization, intravenous hyperalimentation, prior antibiotic use, and the coexistence of other pathogens.

OBJECTIVES

To shed light on the clinical characteristics of MRSA-positive inpatients with head and neck cancers. The secondary goal was to evaluate risk factors for MRSA detection in comparison with methicillin-sensitive S. aureus (MSSA).

PATIENTS AND METHODS

Sixty-one consecutive inpatients with head and neck cancers with S. aureus detection were analyzed based on their medical records. The antimicrobial susceptibility of isolated S. aureus was tested by the broth microdilution method.

RESULTS

MRSA and MSSA were detected in 46 (75.4%) and 15 (24.6%) of the 61 patients, respectively. There was no significant difference in the male/female ratio, age, primary site, comorbidity, cancer stage, cancer treatment, or 5-year survival rate between the MRSA and MSSA groups. Compared with the MSSA group, the MRSA group had significantly longer hospitalization periods and intervals between admission and MRSA detection, as well as significantly greater likelihood of intravenous hyperalimentation, prior antibiotic use, and co-isolation of other pathogens. Isolated strains of MRSA were thoroughly sensitive to vancomycin and arbekacin and moderately sensitive to minocycline.

[Survey of nasopharyngeal carriage of Haemophilus influenzae and Streptococcus pneumoniae in infants at day care centers]

Infants at day care centers tend to contract repetitive upper respiratory infections and prolonged otitis media. The increase in antimicrobial-resistant bacteria, particularly in infants, has given rise to a stubborn therapeutic problem. We studied the nasopharyngeal carriage and drug resistance to Haemophilus influenzae (H. influenzae) and Streptococcus pneumoniae (S. pneumoniae), the most common pathogens of upper respiratory infections, in infants at day care centers. Nasopharyngeal cultures of infants between the ages of 0 and 6 years were conducted at two day care centers in July 2004 ("summer"; n=183), and in February 2005 ("winter"; n=182). Isolated H. influenzae and S. pneumoniae were subjected to antibiotic susceptibility tests by broth microdilution. We also conducted an otolaryngological examination and a survey on past and life histories. H. influenzae in summer (38.3%) increased significantly in winter (57.7%). Beta-lactamase-negative and positive ampicillin-resistant H. influenzae (BLNAR+ BLPAR) in summer decreased significantly in winter. S. pneumoniae did not differ in summer (42.1%) or in winter (43.4%). Penicillin-resistant and intermediate S. pneumoniae (PRSP+PISP) was 41.3% in summer and decreased significantly to 19.0% in winter. BLNAR + BLPAR and PRSP + PISP differed with the day care center. In otolaryngological examination, rhinosinusitis was commonest (28.4% in summer and 30.8% in winter), followed by allergic rhinitis (8.7% in summer and 6.0% in winter) and otitis media (8.2% in summer and 6.0% in winter). Tonsillitis was minor (0.5% in both seasons). Rhinosinusitis in winter was significantly higher in carriers of H. influenzae and/or S. pneumoniae than in non carriers (36.4% versus 16.0%). Breast-fed infants tended to have less otitis media than bottle-fed infants (38.2% versus 52.9%). H. influenzae and/or S. pneumoniae plateaued (75-80%) after 12 months in day care centers. These results suggest that infants attending day care centers are immediately colonized by H. influenzae and S. pneumoniae in the nasopharynx after entering the centers. Nasopharyngeal drug-resistant H. influenzae and S. pneumoniae varied during the seasons and between day care centers. Further prospective studies are needed to determine upper respiratory tract infection in infants at day care centers and to evaluate carriage, epidemiology, and the drug-resistance rates of these pathogens.

Relationships Among Nasal Obstruction, Daytime Sleepiness, and Quality of Life

OBJECTIVES

There has been growing awareness that nasal obstruction may impair various daily and social activities. We performed a questionnaire survey on a working population to clarify the relationships among nasal obstruction, daytime sleepiness, and quality of life (QOL).

METHODS

Seven thousand nine hundred eighty daytime workers were asked to complete questionnaires, and the data from 7,180 subjects without any missing answers were finally analyzed (90.0% of the total participants). The severity of nasal obstruction was graded into the following three categories: never/rarely, sometimes, and always/often. Daytime sleepiness and QOL were assessed by the Epworth Sleepiness Scale and the Medical Outcomes Study 36-Item Short-Form Health Survey, respectively.

RESULTS

Younger subjects reported a higher degree of nasal obstruction. Subjects who reported a higher degree of nasal obstruction had higher daytime sleepiness and lower quality of life. Subjects with higher daytime sleepiness had lower quality of life. The degree of nasal obstruction was not associated with body mass index.

CONCLUSIONS

Taking into account the impact of nasal airway resistance on sleep-disordered breathing, the present results suggest that chronic nasal obstruction impairs QOL, at least partially, through excessive daytime sleepiness possibly caused by sleep-disordered breathing. We stress that sufficient and appropriate rhinologic treatment may improve the quality of daily and social activities of individuals with sinonasal diseases.

Association of verrucous carcinoma and inverted papilloma in the sinonasal tract

It is well known that inverted papilloma (IP) is sometimes associated with malignancies; however, the association of IP with verrucous carcinoma (VC) is extremely rare. We herein report a case of IP in the nasal cavity with VC in the maxillary sinus. A 73-year-old Japanese woman presented with a 3-month history of right-sided nasal obstruction and repetitive epistaxis. A biopsy of the mass was performed and the pathological result proved to be IP. Computed tomography and magnetic resonance imaging revealed a moderately enhanced soft-tissue lesion filling the right nasal cavity and a ring-enhanced expansive lesion in the maxillary sinus. Under a tentative diagnosis of IP of the nasal cavity with maxillary empyema, she underwent right medial maxillectomy via a lateral rhinotomy approach, and a histopathological diagnosis of IP in the nasal cavity with VC in the maxillary sinus was obtained. Her postoperative clinical course was uneventful. She is currently free from symptoms, and there is no evidence of recurrence 5 months after surgery. The pathology, clinical manifestation, and treatment of VC associated with IP are reviewed from literature.

Hyalinizing clear cell carcinoma arising from the base of the tongue

Hyalinizing clear cell carcinoma is a low-grade indolent and rare salivary gland tumor originally described by Milchgrub et al. in 1994. We herein report a case of this tumor of the base of the tongue. A 66-year-old Japanese woman presented with a large painless mass in the throat. Computed tomography and magnetic resonance imaging revealed a 40x30-mm well-defined ovoid tumor arising from the base of the tongue. She underwent tracheostomy followed by a resection of the tumor via the transmandibular approach combined with a right-sided supra-omohyoid neck dissection. Because the tumor invasion of the surrounding tissue was limited, the surgical defect at the base of the tongue was relatively small, and no reconstructive procedure needed to be performed. The tumor was histopathologically diagnosed as hyalinizing clear cell carcinoma of the minor salivary gland. Her postoperative clinical course was uneventful. No aspiration or difficulty upon deglutition was recognized when she started transoral ingestion on the eighth postoperative day. The patient is currently free from disease 21 months after surgery. The pathology, clinical characteristics, and treatment of hyalinizing clear cell carcinoma are bibliographically reviewed.

[Clinical and MRI findings of patients with internuclear ophthalmoplegia]

Internuclear ophthalmoplegia (INO) is a distinctive ocular motor disorder resulting from dysfunction of the medial longitudinal fasciculus, which lies in the pontine tegmentum. We retrospectively analyzed clinical and magnetic resonance imaging (MRI) findings for four consecutive patients with internuclear ophthalmoplegia who were treated in our hospital. The causes of the disease were cerebral infarction in three cases and multiple sclerosis in one case. Vertigo and facial nerve palsy were associated in three cases and one case, respectively. MRI studies visualized an ischemic lesion in the responsible portion of the brainstem in one patient but failed to reveal responsible lesions in the other three patients. All the patients completely recovered in 1 to 22 days, with an average recovery period of 9.3 days. The etiology, diagnosis and management of INO were bibliographically reviewed.

Giant myoepithelioma of the upper lip

Myoepithelioma is a relatively rare form of salivary gland tumor composed entirely of myoepithelial cells. This tumor was formerly considered to be a subtype of pleomorphic adenoma; however, in the latest World Health Organization classification of 1991 it is listed as an independent entity. We report herein an extremely rare case of myoepithelioma of the upper lip. A 78-year-old Japanese female presented with a huge, painless mass on her upper lip. CT and MRI revealed a 50 x 40 mm(2) well-defined ovoid tumor. A benign minor salivary gland tumor was clinically suspected, and the patient underwent complete resection of the tumor under general anesthesia. The surgical defect was immediately reconstructed using an Abbe-Estlander flap. The tumor was histopathologically diagnosed as a benign myoepithelioma of the minor salivary gland. Immunohistochemically, the tumor cells were positive for vimentin, cytokeratins, alpha-smooth muscle actin and S-100 protein, confirming the morphological diagnosis of myoepithelioma. The patient's postoperative clinical course was uneventful, and satisfactory results were obtained both functionally and esthetically. The pathology, clinical manifestations and treatment of myoepithelioma are reviewed.

[A case of spinal epidural abscess associated with retropharyngeal abscess]

Spinal epidural abscesses are known to occur associated with retropharyngeal abscess, but such cases are few in the literature. We treated a 72-year-old woman who reported pain in the back of the neck. Computed tomography (CT) showed a retropharyngeal abscess extending to the upper neck through the carotid space on the left side and an magnetic resonance imaging (MRI) showed a spinal epidural abscess without cervical vertebral osteomyelitis. The abscess was assumed to reach the epidural space along the nerve root through the intervertebral foramen. Since tonsillitis appeared to cause the retropharyngeal abscess, we performed tonsillectomy, and then drained pus through the superior constrictor muscle, effecting a subsequent cure. Staphylococcus aureus was recovered from both the pus and tonsil, and Streptococcus constellatus, a member of the Streptococcus milleri group, from the tonsil. Based on a review of the literature, clinical courses of spinal epidural abscess associated with retropharyngeal abscess are not always simple, as 4 of the 7 cases found demonstrated poor prognosis. Spinal epidural abscess should be considered a critical complication of retropharyngeal abscess.

[Case of acute deep neck infection in a patient with aplastic anemia]

Aplastic anemia often causes a life-threatening infection. We report a case of deep neck infection in a 30-year-old man with aplastic anemia treated with intensive antibiotics after admission, who rapidly recovered without surgery. The infection was caused by dental caries with an immunocompromised host via hemodyscrasia. He remains free from inflammation recurrence 5 months after treatment. We discuss the importance of early, appropriate treatment of deep neck infection associated with aplastic anemia occurring in immunocompromised patients.

Evaluation of bedmaking-related airborne and surface methicillin-resistant Staphylococcus aureus contamination

The number of airborne methicillin-resistant Staphylococcus aureus (MRSA) before, during and after bedmaking was investigated. Air was sampled with an Andersen air sampler in the rooms of 13 inpatients with MRSA infection or colonization. Sampling of surfaces, including floors and bedsheets, was performed by stamp methods. MRSA-containing particles were isolated on all the sampler stages-stage 1 (>7 microm diameter) to stage 6 (0.65-1.1 microm). The MRSA-containing particles were mostly 2-3 microm diameter before bedmaking and >5 microm during bedmaking. The number was significantly higher 15 min after bedmaking than during the resting period, but the differences in counts after 30 and 60 min were not significant. MRSA was detected on many surfaces. The results suggest that MRSA was recirculated in the air, especially after movement. To prevent airborne transmission, healthcare staff should exercise great care to disinfect inanimate environments. Further studies will be needed to confirm the level of MRSA contamination of air during bedmaking and establish measures for prevention of airborne transmission.

Significance of airborne transmission of methicillin-resistant Staphylococcus aureus in an otolaryngology-head and neck surgery unit

OBJECTIVES

To quantitatively investigate the existence of airborne methicillin-resistant Staphylococcus aureus (MRSA) in a hospital environment and to perform phenotyping and genotyping of MRSA isolates to study MRSA epidemiology.

DESIGN

Prospective surveillance of patients with MRSA infections or colonizations was performed, as was an observational study of environmental airAirborne samples were taken by an air sampler; samples were obtained from object surfaces by stamping or swabbing. Epidemiological study of MRSA isolates was performed with an antibiotic susceptibility test, coagulase typing, and pulsed-field gel electrophoresis.

SETTING

Three single-patient rooms in a 37-bed otolaryngology-head and neck surgery unit.

PATIENTS

Three patients with squamous cell head and neck cancer were observed to have been colonized or infected with MRSA after surgery.

RESULTS

The MRSA samples were collected from the air in single-patient rooms during both a period of rest and when bedsheets were being changed. Isolates of MRSA were detected in all stages (from stage 1 [>7 microm] to stage 6 [0.65-1.1 microm]). About 20% of the MRSA particles were within a respirable range of less than 4 microm. Methicillin-resistant S aureus was also isolated from inanimate environments, such as sinks, floors, and bedsheets, in the rooms of the patients with MRSA infections as well as from the patients' hands. An epidemiological study demonstrated that clinical isolates of MRSA in our ward were of one origin and that the isolates from the air and from inanimate environments were identical to the MRSA strains that caused infection or colonization in the inpatients.

CONCLUSIONS

Methicillin-resistant S aureus was recirculated among the patients, the air, and the inamimate environments, especially when there was movement in the rooms. Airborne MRSA may play a role in MRSA colonization in the nasal cavity or in respiratory tract MRSA infections. Measures should be taken to prevent the spread of airborne MRSA to control nosocomial MRSA infection in hospitals.

Relationship of nasal carriage of Staphylococcus aureus to pathogenesis of perennial allergic rhinitis

BACKGROUND

Several studies have previously shown some factors that modify the pathogenesis of perennial allergic rhinitis (PAR). However, the association between bacterial colonization and PAR has not been well understood.

OBJECTIVE

We sought to study the association between superantigen-producing Staphylococcus aureus and PAR.

METHODS

S aureus colonization in the nasal cavity and its superantigen production were studied in 65 patients with PAR and 45 nonallergic control subjects. The nasal symptom scores of the patients were evaluated. Furthermore, we examined the response to staphylococcal enterotoxin B or toxic shock syndrome toxin 1 of peripheral blood lymphocytes from both patients and control subjects by measuring proliferative responses and production of cytokines (IFN-gamma, IL-4, and IL-5).

RESULTS

The rate of nasal carriage of S aureus in the patients (44%) was significantly higher than that of the control subjects (20%, P <.01). Moreover, the rate of nasal carriage of superantigen-producing S aureus in the patients (22%) was significantly higher than that of the control subjects (6.7%, P <.05). The nasal symptom scores of the S aureus -positive patients were significantly higher than those of the S aureus -negative patients (P <.05), although there was no significant association between symptom scores and superantigen production. Peripheral blood lymphocytes from the patients showed significantly higher proliferative responses and were more likely to produce T(H2 )type cytokines in response to superantigens (P <.01), but the responses were not different among the patients with S aureus carriage and superantigen production.

CONCLUSION

This study suggests that PAR leads to a higher carriage rate of S aureus, and nasal carriage of S aureus may aggravate PAR.

Development of a new seminested PCR method for detection of Legionella species and its application to surveillance of legionellae in hospital cooling tower water

The presence of PCR inhibitors in water samples is well known and contributes to the fact that a practical PCR assay has not been developed for legionella surveillance. In this study, we devised a new seminested PCR assay for detection of Legionella spp. in water samples as a means of overriding the PCR inhibitors without loss of sensitivity. The seminested PCR assay utilized primers to amplify the 16S rRNA gene (LEG primers) of 39 Legionella spp. The assay was specific to legionellae, and the sensitivity was 1 fg of extracted Legionella DNA in laboratory examination. To evaluate the feasibility and sensitivity of the PCR assay in identifying the presence of legionellae, it was used to survey Legionella contamination in the water of 49 cooling towers of 32 hospitals. A commercially available EnviroAmp Legionella kit and a culture method were also used in the survey for comparison with the seminested PCR assay. The detection rates of legionellae in the samples were 91.8% (45 of 49) by the PCR assay and 79.5% (39 of 49) by the culture method. The EnviroAmp kit revealed that 30.6% of the water samples (15 of 49) contained inhibitors of the PCR amplification. However, the seminested PCR assay could produce the Legionella-specific DNA bands in 14 of the 15 samples. Although 8 of the 14 samples were positive in the first-step PCR, 6 of the 14 samples became positive in the second-step PCR. These results suggest that the effect of PCR inhibitors in samples, if any, can be reduced because of the dilution of the sample in the second-step PCR and that sensitivity of detection can be increased by the second-step PCR. Thus, the seminested PCR assay with LEG primers to amplify the 16S rRNA gene of 39 Legionella spp. was a practical and sensitive method to detect Legionella spp. in water samples.