[Predictive value of CONUT score and dialysis age for peritoneal dialysis-associated peritonitis]

Objective: To explore the predictive value of controlling nutritional status (CONUT) score and dialysis age for peritoneal dialysis-associated peritonitis (PDAP). Methods: This study was a follow-up study. Patients with end-stage renal disease who received peritoneal dialysis (PD) for the first time in the Department of Nephrology, the Third Affiliated Hospital of Suzhou University from January 2010 to December 2020 were enrolled in the study. Patients were divided into non-peritonitis group, mono group (only once PDAP occurred in one year) and frequent group (twice or more PDAP occurred in one year) according to the occurrence and frequency of PDAP during follow-up. The demographic, clinical and laboratory data of patients were collected, and the body mass index and CONUT score were recorded after half a year. Cox regression analysis was used to screen the relevant factors, and receiver operating characteristic (ROC) curve was used to analyze the predictive value of CONUT score and dialysis age for PDAP. Results: A total of 324 PD patients were included, with 188 males (58.0%) and 136 females (42.0%), and aged［M（Q₁，Q₃）］48 (37, 60) years old. The follow-up time was 33 (19, 56) months. PDAP occurred in 112 patients (34.6%), including 63 patients (19.4%) in mono group and 49 patients (15.1%) in frequent group. Multivariate Cox regression analysis showed that half-year CONUT score (HR=1.159, 95%CI: 1.047-1.283, P=0.004) was a risk factor for PDAP, and the baseline CONUT score (HR=1.194, 95%CI: 1.012-1.408, P=0.036) was a risk factor for frequent peritonitis. The area under ROC curve of baseline CONUT score combined with dialysis age in predicting PDAP and frequent peritonitis was 0.682 (95%CI: 0.628-0.733) and 0.676 (95%CI: 0.622-0.727), respectively. Conclusion: CONUT score and dialysis age have certain predictive value for PDAP, and the predictive value of combined diagnosis is higher, which may be used as a potential predictor for PDAP in PD patients.

Detection of human papillomavirus in cholesteatomas

The presence of human papillomavirus DNA in cholesteatoma may have some role in the development of middle ear cholesteatoma as well as in papilloma. In the present study, polymerase chain reaction and in situ hybridization with human papillomavirus (HPV)-6 and -11 DNA probes were used to detect the presence of HPV DNA in 32 human middle ear cholesteatomas. Only one specimen contained HPV-6 DNA. Although its occurrence may have been coincidental, it is also possible that the hyperproliferative epithelium of cholesteatomas might have some relationship with HPV infections.

Ventilation tube in adults with middle-ear effusion

OBJECTIVE

This study was conducted to analyze the data concerning otitis media with effusion (OME) to configure its etiology, symptomatology, and outcome in adults.

METHOD

A retrospective study of 198 consecutive cases (260 ears) of OME was conducted between July 1988 and June 1996. All of the patients were older than 16 years and were diagnosed for the first time. Tympanograms, initial symptoms, underlying diseases, extrusion of the ventilation tube, and recurrence rate of effusion were analyzed.

RESULTS

Sinusitis was usually seen in patients 16 to 29 and over 60 years old, whereas nasopharyngeal carcinoma was prevalent in patients 30 to 59 years old. Ear stuffiness (75.3%) was the most prevalent initial symptom, followed by hearing impairment (74.2%). One hundred seventy-five ears from 132 patients had been followed up for more than 2 years. In four ears, ventilation tubes were removed by instrument; the ventilation tubes in the remaining 171 ears of 128 patients extruded spontaneously within 20 months (8.6 months on average). Recurrence of effusion within 2 years was noted in 78.8% (78/99 ears) of patients with head and neck tumours and in 27.3% (12/44 ears) of patients with sinusitis.

CONCLUSION

Nasopharyngeal carcinoma and sinusitis were the main etiologies of OME in adults. In addition to treatment of sinusitis, nasopharyngeal check-up is mandatory in adults with OME.

Caloric response and postural control in patients with nasopharyngeal carcinoma after radiotherapy

Since radiotherapy is the treatment of choice for nasopharyngeal carcinoma, the influence of irradiation on the temporal bone is of great concern for these patients. In this study, the caloric test and posturography were used to investigate vestibular function in 41 irradiated patients with nasopharyngeal carcinoma. Caloric testing showed a high incidence of canal paresis; five unilateral and 10 bilateral. Factors such as middle ear effusion had no significant effect on the occurrence of canal paresis. Posturography showed no difference from the control group. The authors conclude that the influence of irradiation on the vestibular apparatus of patients with nasopharyngeal carcinoma might result in a canal paresis, while postural control is preserved. Central compensation may play an important role in the postural control of these patients.

Head-shaking nystagmus: a sensitive indicator of vestibular dysfunction

This study investigated 258 consecutive patients with the complaint of vertigo undergoing vestibular function tests between August 1992 and July 1994. The head-shaking nystagmus test was performed in a passive fashion with the patient placed in a sitting position with the head anteflexed at 30 degrees and oscillated +/- 45 degrees horizontally for 30 cycles in 15 s; the post head-shaking nystagmus was recorded by electronystagmography. Conventional bithermal caloric tests were conducted with the normal limit of canal paresis set at 20%. The results show significant correlation between head-shaking nystagmus and canal paresis. Head-shaking nystagmus is more sensitive than canal paresis in predicting vestibular dysfunction. The sensitivity of head-shaking nystagmus in detecting a canal paresis was 90%. Although the direction of head-shaking nystagmus does not always accord with the side of peripheral vestibular dysfunction, it is an indicator of vestibular dysfunction and this test could be performed easily as a screening test in every otoneurological investigation.

Toothache with a multifactorial etiology: a case report

A case report of orofacial pain originating from both dental and nondental conditions is presented. The spontaneous throbbing pain initiated from the left maxillary second premolar and spread throughout the entire upper part of the face to the frontoparietal area. Root canal treatment of the maxillary second premolar did not resolve the chief complaint. Magnetic resonance imaging examination revealed hypertrophy of the left inferior turbinate and soft tissue haziness in the left maxillary sinus floor. After antrostomy, submucosal turbinectomy, and endodontic treatment, the patient was free from pain. The final diagnosis of this case, in addition to pulpitis, was maxillary sinusitis with chronic rhinitis. The multiple factors associated with the etiology made the diagnosis difficult. The mechanism of referred pain from the maxillary sinus and paranasal mucosa to the maxillary teeth and face is discussed.

Middle-ear disease in children exposed prenatally to polychlorinated biphenyls and polychlorinated dibenzofurans

During 1978 and 1979, an episode of poisoning from ingestion of rice oil contaminated with polychlorinated biphenyls and polychlorinated dibenzofurans occurred in central Taiwan. We followed-up children who had been born between June 1978 and March 1985, as well as matched unexposed children. The mothers of exposed children had consumed contaminated oils before the children were born. In 1993, otolaryngologists examined the middle ear of each child with a pneumatic otoscope, and they measured the middle-ear pressure by tympanometry with a Rion RS20 impedance audiometer. The exposed children had a significantly higher prevalence of middle-ear diseases than their matched controls. The exposed children who had ear diseases had higher serum levels of 2,3,4,7,8-pentachloro- and 1,2,3,4,7,8-hexachloro-dibenzofurans than the children who did not have similar diseases. Therefore, in this study, children exposed to polychlorinated biphenyls and polychlorinated dibenzofurans had a higher incidence of middle-ear diseases than their controls.

High prevalence of human papillomavirus types 16 and 18 in middle-ear carcinomas

Chronic suppurative otitis media, averaging 20 or more years of duration, has been associated with cancer in this region in 40%-80% of cases. Although human papillomaviruses (HPV) have been implicated in many human squamous-cell neoplasms, their role in the pathogenesis of middle-ear malignancies remains unexplored. In this study, we investigated the presence and subtypes of HPV in middle-ear carcinomas. Formalin-fixed and paraffin-embedded tumor tissues were sampled for DNA extraction. PCR was done with consensus primers, capable of detecting HPV 16, 18, 31, 33, 52b and 58. Typing of the products generated by consensus primers was performed with restriction enzyme digestion. It was found that a resulting 89% (8/9) of the middle-ear carcinomas contained HPV DNA. Coexistence of HPV 16 and 18 was detected in 3 squamous-cell carcinomas. HPV 16 was detected in 4 squamous-cell carcinomas and 1 adenocarcinoma. The high prevalence of high-risk-type HPV in carcinomas of the middle ear suggests that viral infection may be an important etiologic component in the carcinogenic process.

Prevalence of human papillomavirus in middle ear carcinoma associated with chronic otitis media

Squamous cell carcinoma of the middle ear (MESCC) is an uncommon tumor and is associated with a history of long-term chronic otitis media (COM) in most cases. Although the human papillomaviruses (HPVs) have been implicated in many human neoplasms, its role in the pathogenesis of MESCC has not been studied. Polymerase chain reaction (PCR) using consensus primers for the detection of HPV types 6, 11, 16, 18, 31, 33, 52b, and 58 was applied in screening fourteen cases of MESCC from archival material. Further subtyping was performed by restriction enzyme digestion of PCR products and by in situ hybridization method on tissue sections. Of the fourteen cases of MESCC, eleven were found to have HPV DNA. HPV-16 was detected in all positive cases. Five cases revealed both HPV-16 and -18. A history of long-term COM (> 3 years) was found in thirteen of the cases. This is the first report to localize HPV-16/18 in MESCC on both the tissue level and the molecular level. The high prevalence of HPV in COM-associated MESCC therefore provides a good model to explain the pathogenesis of chronic-inflammation-related human malignancies.

Neurobehavioral effects of occupational exposure to low-level organic solvents among Taiwanese workers in paint factories

At six paint factories in northern Taiwan, 325 workers participated in a detailed evaluation that included medical and occupational questionnaires, blood sampling, neurobehavioral tests, vibratory perception threshold tests, and thermal perception threshold tests. Because of cultural differences, a Chinese test battery was modified from the Neurobehavioral Evaluation System 2. Eleven tests were performed: finger tapping, continuous performance, associated learning, symbol-digit, pattern comparison, pattern memory, visual digit span, switch attention, associated delayed recognition, mood scales, and vocabulary. Air concentrations of organic solvents were measured by passive personal samplers and analyzed by gas chromatography. Results showed that major solvents to which the workers were exposed were toluene, xylene, n-hexane, methyl iso-butyl ketone, and n-butyl acetate. The exposure index (EI) was classified by different exposure patterns and different air concentrations in the breathing zone as follows: EI 0, nonexposure; EI 1, low exposure; and EI 2, high exposure (the medians of 8-hr hygienic effects were 0, 0.03, and 0.25, respectively). Because of their diverse socioeconomic status and demographic characteristics, the workers were divided into two groups for additional analysis: one group comprised white-collar workers, including technicians and administrative staff, and the other comprised blue-collar workers. By using multiple linear regression analysis controls for age, sex, education, and alcohol intake, significant associations were found between increased exposure to solvent mixtures and performance on some neuropsychologic tests. In the blue-collar group, significantly prolonged response latencies were observed in the tests of continuous performance, pattern comparison, and pattern memory. Among white-collar workers, significant impairment was observed in the continuous performance test. All three tests involved visual attention and perceptual (speed and memory) functions. It was concluded that these may be the earliest neurotoxic signs of occupational exposure to low-level organic solvents in paint manufacturing workers.

Eustachian tube dysfunction in the pathogenesis of cholesteatoma: clinical considerations

OBJECTIVE

This study was conducted to gain insight into the surgical management of cholesteatomas to prevent postoperative retraction of the tympanic membrane.

DESIGN

A retrospective chart review of patients presenting between July 1988 and July 1992 was conducted.

METHOD

Clinical observations were made on 85 ears from 81 patients who had tympanoplasty with mastoidectomy for middle ear cholesteatoma, with ossicular reconstruction if necessary, with a subsequent follow-up period of 36 to 84 months (mean, 60 +/- 13 months).

RESULTS

The tympanic membrane in several cases became gradually retracted postoperatively; retraction generally commenced along the margin of the cartilage used for repairing the scutum defect, and was noted as early as 9 months, and after 5 years' follow-up, in as much as 66% in the 44 ears operated.

CONCLUSIONS

Eustachian tube dysfunction was common postoperatively in cholesteatomatous ears; however, whether it was the etiology or the sequela of a cholesteatoma could not be deduced. Since a retraction pocket in the tympanic membrane can develop into a cholesteatoma, it may account for some cases with recurrence of cholesteatoma postoperatively. Therefore, the cartilage/perichondrium composite graft for repairing the bone defect should be as large as possible.

Ultrastructure of eustachian tube mucosa in chronic otitis media with cholesteatoma

PURPOSE

Acquaintance with the severity of inflammatory condition and mucociliary destruction of the protympanic eustachian tube (ET) mucosa may provide some insight for management during surgery for cholesteatoma.

MATERIALS AND METHODS

Protympanic eustachian mucosa was obtained from 25 patients undergoing ear surgery for cholesteatoma and from 5 cadavers undergoing dissection for a gross anatomy course. The specimens were processed for both scanning electron microscopy (SEM) and transmission electron microscopy (TEM).

RESULTS

According to SEM, decreased ciliated cells were noted. Residual ciliated cells and numerous white blood cells (WBC) were noted in the protympanic mucosa of the eustachian orifice. Bacilli were commonly noted at the mucosal surface. Cilia might be collapsed and stagnated with mucus secretion. This finding was consistent with those of the TEM: that cilia of varied directions were embedded in mucus. Mucociliary function was impaired under such conditions. The mucosal alteration was severe in some children; there was no ciliated cell visible. According to the TEM, the mucosal cells contained numerous secretory granules and mitochondria. Polymorphous nuclear cells were noted in the submucosal area that was edematous. Compound cilia were rather common. Mucus blanket covered mucosal cells with widening intercellular spaces. In addition, neither cilia nor microvilli were visible in severe mucosal alteration.

CONCLUSIONS

These occurrences indicated the presence of inflammatory reaction and impairment of clearance function of eustachian mucosa in cholesteatomatous ears. Thorough irrigation during surgery and antimicrobial therapy after surgery are warranted.

Ultrastructure of the middle ear mucosa in patients with chronic otitus media with cholesteatoma

Mucosa of the middle ear was obtained from the promontory wall in each of 20 patients during cholesteatoma surgery. Specimens were processed for both scanning and transmission electron microscopy. Non-ciliated mucosal cells were commonly found, with most being secretory cells with secretory droplets and microvilli. The patterns of distribution of microvilli on the surface of these cells were variable. The interciliary spaces were stagnated with secretion. Bacilli were present in five cases. Falloff of mucosal cells was common and intercellular spaces were widened. Compound cilia were observed sporadically. Polymorphic nuclear inflammatory cells, macrophages and fibroblasts appeared in the submucosal area. These findings indicate that although remaining adjacent mucosa after removal of cholesteatoma looks free of disease under the operating microscope, it is actually in a diseased condition with impaired mucociliary function. The cells and bacteria seen microscopically may account for postoperative inflammation, thus warranting continued postoperative antimicrobial medication.

Effects of irradiation on the rat middle ear mucosa. A scanning electron microscopic study

Adult Sprague-Dawley rats (n = 64) were used in this study to replicate in an animal model tissue change formed clinically during radiotherapy for the treatment of head and neck malignancy. Gamma irradiation was administered to both ears of each rat, using a cobalt-60 machine. A total dose of 30 Gy was administered, with 500 cGy/fraction given on 6 consecutive days to a time-dose fractionation value of 81. Animals were then sacrificed at sequential intervals. The tympanic bullae were removed and the mucosa was processed for scanning electron microscopy. Tissue findings indicated that irradiation might initially have no influence on the clearance activity of the middle ear. However, ultrastructural changes showed stagnation of secretion between cilia, falling off and different directions of the cilia, fused or collapsed cilia, and eustachian tube dysfunction (with mucosal edema). These findings possibly account for the occurrence of middle ear effusions in patients during and after radiotherapy for head and neck malignancy. It is our concept that insertion of a ventilation tube is necessary if abnormal mucociliary function appears, in order to clear and prevent the accumulation of any middle ear effusions and prevent further mucociliary dysfunction.

Hearing impairment in chronic otitis media with cholesteatoma

This study involved a five-year review of 94 patients with chronic otitis media with cholesteatoma. In total, 110 surgical procedures were carried out. The study comprised 96 cases; surgery that was a revision of previous surgery were excluded. The extent of cholesteatoma and its associated bone destruction were observed and recorded. Of the 96 cases, 14.6% were classified as Grade I, 13.5% as Grade II, 31.3% as Grade III and 40.6% as Grade IV. This indicated that the majority of patients with chronic otitis media with cholesteatomas were in an advanced stage. Preoperative pure tone audiogram showed that 49% of these patients had pure conductive hearing impairment; 29.2% had a mixed type hearing impairment; 15.6% had a sensorineural hearing impairment and only 6.2% had normal hearing. In 78% of these cases, the conductive component of hearing loss was improved with surgery. If 40 db was used as a standard for the social hearing level, 72.9% of these cases were handicapped.

[Congenital CSF otitic leakage presenting as rhinorrhea: report of a case]

A 10-year-old girl was brought to our ear, nose and throat clinic for consultation on her articulation problem in addition to an attack of bacterial meningitis and cerebrospinal fluid (CSF) rhinorrhea. These problems had bothered her and her family for about 5 years. In August 1988, she had received a bifrontal osteoplastic craniotomy for her CSF leakage, but the procedure was ineffective. Local examination showed bilaterally intact ear drums. The left ear drum looked cloudy and thick with poor mobility under pneumatoscopy. A tympanogram showed that B type. Pure tone audiometry revealed a profound sensorineural hearing loss in the left ear. A CT scan showed widening of the internal auditory canal and dysplasia of the left cochlea and vestibule in addition to fluid accumulation in the mastoid and mesotympanum. Under the impression of CSF otorrhea, an exploratory tympanotomy was performed, revealing an area of leakage in the tympanic cavity. It was sealed with abdominal fat, temporal connective tissue and tissue glue. All of the bothersome symptoms disappeared postoperatively during an 18-month follow-up.

Langerhans cells in human middle ear cholesteatomas

Langerhans cells have been found in cholesteatomas for many years. It is believed that they are immunocompetent cells and have the same role in cell-mediated immunologic mechanisms in cholesteatoma as well as in skin. This study used the transmission electron microscope to observe the cellular characteristics of Langerhans cells and the apposition phenomenon of Langerhans cells with lymphocyte-like cells in human middle ear cholesteatomatous tissue. These findings are evidence for cell-mediated immune responses in middle ear cholesteatomas. In vitro Langerhans cells conditioned medium prepared from Lewis rat skin was used to show its effects on protein synthesis and the differentiation of basal cells. Since the cellular behaviour of basal cells is important in the development and pathogenesis of cholesteatoma, the present study shows that Langerhans cells may have some role in the clinical formation of a cholesteatoma. Since cells extracted from rat skin may have a different response from that of cells from human middle ear cholesteatoma, further investigations are necessary to compare the biological effects of both tissues.

Expression of involucrin in human middle ear cholesteatoma

Immunolocalization of involucrin in human middle ear cholesteatoma was performed with specific rabbit anti-human involucrin antibody. Involucrin was noted prominently in the cytoplasm of the suprabasal cells, including spinous cells and granular cells. The pattern of distribution of involucrin in cholesteatoma shows its epidermal characteristics. Immunostaining of involucrin was also made in tympanic membrane and external ear canal skin. As for comparing its distribution, a larger amount of involucrin was present in cholesteatoma (60%) than in external ear canal skin (29%) in our study and in normal skin (25%) in another study. This suggests active differentiation of the epithelial cells in cholesteatoma. Further investigation on the inhibition of involucrin formation may have some effect in the treatment of cholesteatoma.

An immunocytochemical study of cytokeratin expression in human middle ear cholesteatoma

An indirect immunofluorescent method with monoclonal anti-cytokeratin antibodies was used to localize various cytokeratins in human middle ear cholesteatoma. The 50 K/58 K and 56.5 K/65-67 K paired cytokeratins are markers of skin type and were found in the specimens of human middle ear cholesteatomas studied. In contrast, the 40 K and 45 K cytokeratins (markers of simple epithelia), the 48 K cytokeratin (marker of hyperproliferative epidermal disease) and the 51 K cytokeratin (marker of internal organ epithelia) were absent in human middle ear cholesteatoma. These findings indicate that the pattern of cytokeratins in human middle ear cholesteatoma is similar to that of skin but is different from those of simple epithelium, internal organ epithelia, and hyperproliferative epidermal disease. These findings also support the skin type epithelial origin of cholesteatoma and strongly favor the migration theory in the genesis of cholesteatomas.

Localization of filaggrin in human middle ear cholesteatoma

Filaggrin, a histidine-rich protein, was located immunohistochemically in human middle ear cholesteatoma by specific antibody. It was found to be localized in the cytoplasm of the granular layer cells and cornified layer. The pattern of distribution is similar to that of epidermis. Filaggrin is a major component of keratohyalin which is a distinct component of the differentiating epidermal cells. Thus the presence of filaggrin in cholesteatoma suggests epidermal characteristics of the cholesteatoma.

Effects of granulation tissue conditioned medium on the in vitro differentiation of keratinocytes

The accumulation of desquamated keratinizing squamous epithelial cells appears to be a crucial factor in the pathogenesis of middle ear cholesteatomas. The accumulation of keratin debris is due to the proliferation and the terminal differentiation of basal keratinocytes. Since cholesteatomas are usually associated with inflammatory reactions in the middle ear cavity, we examined the effects of a granulation tissue conditioned medium on the terminal differentiation of basal keratinocytes in vitro. This conditioned medium stimulated the terminal differentiation of basal keratinocytes by showing: (a) increased incorporation of 3H-leucine into cell envelopes; (b) an increased number of SDS-insoluble cell envelopes; and (c) increased transglutaminase activity (as a marker for terminal cellular differentiation). Our present studies further suggest that inflammatory granulation tissue plays an important role in the clinical growth and development of the cholesteatoma.

Localization of fibronectin in human middle ear cholesteatoma

Fibronectin was localized in human cholesteatoma tissues by immunohistochemical methods. The avidin-biotin-peroxidase complex staining method was used with specific fibronectin antibody. Fibronectin appeared to be localized in the matrix of the cholesteatoma studied, particularly on the surface of the cell membranes and the nuclei of the basal cells and in connective tissue. Fibronectin was not seen in the granular layer or in the keratin area. Fibronectin was found on the surface of granulation tissue, mononuclear cells, fibroblasts and endothelial cells of blood vessels. These findings were confirmed by the immunofluorescent staining method. Our previous study showed that fibronectin induced a migration of keratinocytes, macrophages and fibroblasts demonstrated by the Boyden's chamber chemotaxis assay. Macrophages and fibroblasts were shown to produce collagenase, a bone resorption factor, in cholesteatomatous tissue. The present study showed the presence of fibronectin in the matrix of cholesteatoma and granulation tissue, suggesting that fibronectin might play an important role in the clinical development and invasive behavior of cholesteatoma.