Research Application of Laser-induced Shock Wave for Studying Blast-induced Cochlear Injury

The ear is the organ most susceptible to explosion overpressure, and cochlear injuries frequently occur after blast exposure. Blast exposure can lead to sensorineural hearing loss (SNHL), which is an irreversible hearing loss that negatively affects the quality of life. Detailed blast-induced cochlear pathologies, such as the loss of hair cells, spiral ganglion neurons, cochlear synapses, and disruption of stereocilia, have been previously documented. However, determining cochlear sensorineural deterioration after a blast injury is challenging because animals exposed to blast overpressure usually experience tympanic membrane perforation (TMP), which causes concurrent conductive hearing loss. To evaluate pure sensorineural cochlear dysfunction, we developed an experimental animal model of blast-induced cochlear injury using a laser-induced shock wave. This method avoids TMP and concomitant systemic injuries and reproduces the functional decline in the SNHL component in an energy-dependent manner after LISW exposure. This animal model could be a platform for elucidating the pathological mechanisms and exploring potential treatments for blast-induced cochlear dysfunction.

Experiences of Percutaneous Endoscopic Approach for the Mastoid Lesions: A Novel Minimally Invasive Ear Surgery

OBJECTIVES

We developed a novel keyhole surgery, named "percutaneous endoscopic ear surgery" (PEES), with the aim of further reducing the invasiveness of otologic surgery. We reported the cases we encountered and retrospectively analyzed the invasiveness of PEES.

METHODS

We analyzed the ears of eight patients who underwent PEES for mastoid lesions that could not be manipulated with transcanal endoscopic ear surgery (TEES) at our hospital between July 2021 and November 2022. We performed PEES alone in three patients, including one case of type A (preauricular incision) and two cases of type B (retroauricular incision). The last five patients underwent combined endoscopic ear surgery, which is simultaneous PEES and TEES. In these cases, one patient underwent type A PEES, and four patients underwent type B PEES.

RESULTS

PEES was performed in all patients without converting to conventional microscopic mastoidectomy. The mean length of skin incisions was 19.1 ± 4.5 mm, which was smaller than that in conventional mastoidectomy. In all cases, the average length of the major axis of the keyhole was <10 mm, indicating that sufficient minimally invasive surgery was achieved. The average depth from the keyhole to the deepest site was 21.6 ± 8.9 mm. There was no change in the mean hearing level before and after the surgery.

CONCLUSION

PEES is a minimally invasive procedure for manipulating lesions in the mastoid. In addition, the combination of PEES and TEES is an ideal, minimally invasive procedure that can be used to treat all regions of the temporal bone.

Blast-Induced Central Auditory Neurodegeneration Affects Tinnitus Development Regardless of Peripheral Cochlear Damage

Blast exposure causes serious complications, the most common of which are ear-related symptoms such as hearing loss and tinnitus. The blast shock waves can cause neurodegeneration of the auditory pathway in the brainstem, as well as the cochlea, which is the primary receptor for hearing, leading to blast-induced tinnitus. However, it is still unclear which lesion is more dominant in triggering tinnitus, the peripheral cochlea or the brainstem lesion owing to the complex pathophysiology and the difficulty in objectively measuring tinnitus. Recently, gap detection tests have been developed and are potentially well-suited for determining the presence of tinnitus. In this study, we investigated whether the peripheral cochlea or the central nervous system has a dominant effect on the generation of tinnitus using a blast-exposed mouse model with or without earplugs, which prevent cochlear damage from a blast transmitted via the external auditory canal. The results showed that the earplug (+) group, in which the cochlea was neither physiologically nor histologically damaged, showed a similar extent of tinnitus behavior in a gap prepulse inhibition of acoustic startle reflex test as the earplug (-) group, in which the explosion caused a cochlear synaptic loss in the inner hair cells and demyelination of auditory neurons. In contrast, both excitatory synapses labeled with VGLUT-1 and inhibitory synapses labeled with GAD65 were reduced in the ventral cochlear nucleus, and demyelination in the medial nucleus of the trapezoid body was observed in both groups. These disruptions significantly correlated with the presence of tinnitus behavior regardless of cochlear damage. These results indicate that the lesion in the brainstem could be dominant to the cochlear lesion in the development of tinnitus following blast exposure.

Effects of Unilateral Vagotomy on LPS-Induced Aspiration Pneumonia in Mice

Respiratory-related dysphagia and aspiration pneumonia can be attributed to multiple causes. However, reproduction of multiple factor-related respiratory distress and aspiration pneumonia in a single animal model is challenging. To validate animals with vagal nerve palsy as novel models for severe aspiration pneumonia associated with respiratory distress, we investigated the effects of unilateral vagotomy on the swallowing function and severity of pneumonia after forced aspiration in mice. Unilateral vagotomy was performed in C57BL6 male mice that subsequently underwent evaluation of swallowing function by videofluoroscopic swallow study (VFSS) and histological assessments for aspiration pneumonia induced by lipopolysaccharide (LPS). VFSS examinations demonstrated that unilateral vagotomy did not cause apparent aspiration in mice, but it resulted in a significant loss of body weight (BW) due to decreased oral intake. In addition, when aspiration pneumonia was induced by forced administration of LPS, significantly prolonged BW loss and severe infiltration of inflammatory cells associated with aspiration pneumonia were observed in the mice that underwent unilateral vagotomy. In conclusion, the vagotomized mice showed appropriate characteristics as a model of aspiration pneumonia caused by multiple factors, including the paralysis of vocal fold movement and respiratory distress. This model can help elucidate the pathogenesis of aspiration pneumonia and the treatment methods for the respiration-compromised model.

Factors affecting the incidence of chorda tympani nerve transection in middle ear surgery

Objective

To reveal the factors affecting the incidence of chorda tympani nerve (CTN) transection during middle ear surgery.

Study Design

Retrospective case review.

Setting

Tertiary referral center.

Patients

We analyzed 232 ears (117 ears with cholesteatoma, 101 ears with chronic otitis media, and 14 ears with otosclerosis) that underwent tympanoplasty or stapes surgery during 2017-2020.

Intervention

Eighty-four ears underwent transcanal endoscopic ear surgery (TEES), 103 ears underwent microscopic ear surgery (MES), and 45 ears underwent surgery using both endoscopy and microscopy (Dual).

Main Outcome Measure

To confirm CTN transection, intraoperative endoscopic/microscopic video images were evaluated. We used the same video images to determine the anatomical variation of the CTN course in the middle ear.

Results

In 18 ears (7.8%: 6/84 TEES ears [7.1%], 6/103 MES ears [5.8%], and 6/45 Dual ears [13.3%]), the CTN was cut during middle ear surgery. There was no significant difference in CTN transection among groups. In cholesteatoma patients, stapes involvement resulted in a significantly higher CTN transection incidence. CTN anatomical variants such as the "Attached Short type" and "Ultrashort type" showed a significantly higher CTN transection incidence.

Conclusion

Although endoscopic surgery did not reduce the incidence of CTN transection during middle ear surgery, pathological involvement of the stapes and CTN anatomical variants, such as the "Attached Short type" and "Ultrashort type," may increase this incidence. Preoperative evaluation of stapes involvement and anatomical location of the CTN course could help identify patients at greater risk for iatrogenic CTN transection.

Level of Evidence

4.

Correlation of blast-induced tympanic membrane perforation with peripheral cochlear synaptopathy

The auditory organs, including the tympanic membrane, cochlea, and central auditory pathway, are the most fragile components of the human body when exposed to blast overpressure. Tympanic membrane perforation (TMP) is the most frequent symptom in blast-exposed patients. However, the impact of TMP on the inner ear and central auditory system is not fully understood. We aimed to analyze the effect of blast-induced TMP on the auditory pathophysiological changes in mice after blast exposure. Mice aged 7 weeks were exposed to blast overpressure to induce TMP and allowed to survive for 2 months. All TMP cases had spontaneously healed by week 3 following the blast exposure. Compared to controls, blast-exposed mice exhibited a significant elevation in hearing thresholds and an apparent disruption of stereocilia in the outer hair cells, regardless of the occurrence or absence of TMP. The reduction in synapses in the inner hair cells, which is known as the most frequent pathology in blast-exposed cochleae, was significantly more severe in mice without TMP. However, a decrease in the number of excitatory central synapses labeled by VGLUT-1 in the cochlear nucleus was observed regardless of the absence or presence of TMP. Our findings suggest that blast-induced TMP mitigates peripheral cochlear synaptic disruption but leaves the central auditory synapses unaffected, indicating that central synaptic disruption is independent of TMP and peripheral cochlear synaptic disruption. Synaptic deterioration in the peripheral and central auditory systems can contribute to the promotion of blast-induced hearing impairment, including abnormal auditory perception.

Effect of shock wave power spectrum on the inner ear pathophysiology in blast-induced hearing loss

Blast exposure can induce various types of hearing impairment, including permanent hearing loss, tinnitus, and hyperacusis. Herein, we conducted a detailed investigation of the cochlear pathophysiology in blast-induced hearing loss in mice using two blasts with different characteristics: a low-frequency dominant blast generated by a shock tube and a high-frequency dominant shock wave generated by laser irradiation (laser-induced shock wave). The pattern of sensorineural hearing loss (SNHL) was low-frequency- and high-frequency-dominant in response to the low- and high-frequency blasts, respectively. Pathological examination revealed that cochlear synaptopathy was the most frequent cochlear pathology after blast exposure, which involved synapse loss in the inner hair cells without hair cell loss, depending on the power spectrum of the blast. This pathological change completely reflected the physiological analysis of wave I amplitude using auditory brainstem responses. Stereociliary bundle disruption in the outer hair cells was also dependent on the blast’s power spectrum. Therefore, we demonstrated that the dominant frequency of the blast power spectrum was the principal factor determining the region of cochlear damage. We believe that the presenting models would be valuable both in blast research and the investigation of various types of hearing loss whose pathogenesis involves cochlear synaptopathy.

Y-27632, a ROCK inhibitor, improved laser-induced shock wave (LISW)-induced cochlear synaptopathy in mice

Recently, a pathological condition called cochlear synaptopathy has been clarified, and as a disorder of the auditory nerve synapses that occurs prior to failure of hair cells, it has been recognized as a major cause of sensorineural hearing loss. However, cochlear synaptopathy is untreatable. Inhibition of rho-associated coiled-coil containing protein kinase (ROCK), a serine-threonine protein kinase, has been reported to have neuroprotective and regenerative effects on synaptic pathways in the nervous system, including those in the inner ear. We previously demonstrated the regenerative effect of the ROCK inhibitor, Y-27632, on an excitotoxic cochlear nerve damage model in vitro. In this study, we aimed to validate the effect of ROCK inhibition on mice with cochlear synaptopathy induced by laser-induced shock wave (LISW) in vivo. After the elevation of ROCK1/2 expression in the damaged cochlea was confirmed, we administered Y-27632 locally via the middle ear. The amplitude of wave I in the auditory brainstem response and the number of synapses in the Y-27632-treated cochlea increased significantly. These results clearly demonstrate that ROCK inhibition has a promising clinical application in the treatment of cochlear synaptopathy, which is the major pathology of sensorineural hearing loss.

Risk factors of post-tonsillectomy hemorrhage in adults

OBJECTIVE

Tonsillectomy is an essential surgery and is conducted on both children and adults. However, the risk factors of post-tonsillectomy hemorrhage for adult patients remain unclear. In this study, we analyzed post-tonsillectomy hemorrhage in adult patients.

METHODS

We retrospectively analyzed 325 adult patients who underwent a tonsillectomy between 2014 and 2018 in our facilities.

RESULTS

The average age of this study's population was 31.7 ± 10.5 years (range: 19-70 years), and 250 (76.9%) patients were male. Overall, post-tonsillectomy hemorrhage occurred in 71 (21.8%) patients and 5 (1.5%) patients required a second surgery for hemostasis. Post-tonsillectomy hemorrhage often occurred on postoperative day zero or six. Using multiple logistic regression analysis, current smoking status (odds ratio 3.491; 95% confidence interval 1.813-6.723), male sex (odds ratio 3.924; 95% confidence interval 1.548-9.944), and perioperative non-steroidal anti-inflammatory drug administration (odds ratio 7.930; 95% confidence interval 1.004-62.64) were revealed as overall post-tonsillectomy hemorrhage risk factors. To analyze the hemorrhage period after tonsillectomy, we categorized the post-tonsillectomy hemorrhage patients into the primary (bleeding within postoperative day one) and secondary hemorrhage (bleeding on or after postoperative day two) groups. The current smoking status and older age were risk factors for primary hemorrhage and the current smoking status and sex (male) were risk factors for secondary hemorrhage.

CONCLUSIONS

In this study, smoking status, sex, and perioperative non-steroidal anti-inflammatory drug administration were the clinical risk factors for adult post-tonsillectomy hemorrhage. Thus, smoking cessation is, at least, mandatory for patients who receive tonsillectomy to avoid post-tonsillectomy hemorrhage.

LEVEL OF EVIDENCE

4.

Regenerative Effect of a ROCK Inhibitor, Y-27632, on Excitotoxic Trauma in an Organotypic Culture of the Cochlea

In the past, most inner ear diseases were thought to start with the impairment of the sensory epithelium of the cochlea before subsequently progressing to secondary neural degeneration. However, recent studies show that loss of primary synapses accompanied by excitotoxic degeneration of peripheral axons is likely to be the underlying pathology in sensorineural hearing loss. Rho-associated coiled-coil containing protein kinase (ROCK) inhibition has been reported to have neuroprotective and regenerative effects on synaptic pathways. Therefore, we analyzed the effect of ROCK inhibition using Y-27632 in a model of peripheral axonal damage in the spiral ganglion neurons created using the glutamate agonists, N-methyl-D-aspartate (NMDA) and kainic acid, to induce excitotoxic trauma in the explanted cochlea. The number of axons projecting to hair cells in the cochlea treated with Y-27632 was significantly greater than those in the cochlea treated only with NMDA + kainic acid. Furthermore, there was a significant increase in synapses between the spiral ganglion and the inner hair cells in the cochlea treated with Y-27632. The findings of this study suggest that ROCK inhibition could be a potential strategy for the regeneration of peripheral axons in the spiral ganglion and synapse formation in the inner hair cells of a cochlea that has sustained excitotoxic injury, which is one of the primary etiologies of inner ear disease.

Tinnitus rat model generated by laser-induced shock wave; a platform for analyzing the central nervous system after tinnitus generation

OBJECTIVE

Tinnitus is a phantom auditory sensation, which is mainly triggered by dysfunction of the peripheral auditory organ, such as cochlear disorders. Additionally, the central nervous system, specifically the limbic system, plays a crucial role in the generation and exacerbation of tinnitus. Therefore, to analyze the hypothesis that tinnitus has strong and specific association with the plastic changes in the limbic system, we assessed the neuronal plastic changes in the limbic system, including the hippocampus and the amygdala, in rats with single-sided tinnitus.

METHODS

The cochlear damage was achieved by irradiating the cochlea with laser-induced shock wave (LISW). While both hearing loss and tinnitus were confirmed after exposure of rats to LISW, the degree of tinnitus was objectively measured using gap detection behavioral tests. Following the generation of hearing loss and tinnitus, plastic changes in the neurons of the limbic system were confirmed using a molecular marker (activity regulated cytoskeleton-associated protein; Arc).

RESULTS

While the expression level of Arc-positive cells in the hippocampal CA1 showed an obvious increase in the hearing loss and tinnitus groups, a significant difference was found between the tinnitus and the control groups. In the dentate gyrus, although the largest number of Arc-positive cells was observed in the tinnitus group, there were no significant differences between the numbers of cells in the hearing loss and tinnitus groups compared to that in the control group.

CONCLUSION

Although a significant increase of Arc-positive cells in the hippocampal CA1 was observed between the tinnitus group and control, no obvious tendencies of Arc-positive cells in the limbic system were observed between the rats with and without tinnitus behavior.

A Case of Gastric Meningeal Carcinomatosis Involving Bilateral Hearing Loss: The Difference between Clinical Images and Autopsy Findings

We describe a rare case of meningeal carcinomatosis (MC) in a 66-year-old man who presented with bilateral deafness and vertigo, initially presumed to be neurofibromatosis type-2. Brain magnetic resonance imaging (MRI) of the patient revealed bilateral gadolinium enhanced masses at the cerebellopontine angle. However, multiple central nervous system symptoms, including loss of consciousness, gradually appeared. He had a history of gastric cancer; therefore, a lumbar puncture was performed. Cytological examination of the cerebrospinal fluid confirmed the presence of adenocarcinoma cells. The general condition of this patient worsened, and he died 46 days after the first onset of hearing loss. An autopsy was performed, and multiple infiltrations of adenocarcinoma cells in the brain were confirmed, though undetected by MRI. The prognosis of MC is extremely poor; therefore, rapid diagnosis is important to prevent mortality. Retrospectively, a lumbar puncture could have been conducted earlier to identify MC, especially in consideration of the clinical history of this patient.

Blast-induced hearing loss

The incidence of blast injury has increased recently. As the ear is the organ most sensitive to blast overpressure, the most frequent injuries seen after blast exposure are those affecting the ear. Blast overpressure affecting the ear results in sensorineural hearing loss, which is untreatable and often associated with a decline in the quality of life. Here, we review recent cases of blast-induced hearing dysfunction. The tympanic membrane is particularly sensitive to blast pressure waves, since such waves exert forces mainly at air-tissue interfaces within the body. However, treatment of tympanic membrane perforation caused by blast exposure is more difficult than that caused by other etiologies. Sensorineural hearing dysfunction after blast exposure is caused mainly by stereociliary bundle disruption on the outer hair cells. Also, a reduction in the numbers of synaptic ribbons in the inner hair cells and spiral ganglion cells is associated with hidden hearing loss, which is strongly associated with tinnitus or hyperacusis.

Protein transduction therapy into cochleae via the round window niche in guinea pigs

Cell-penetrating peptides (CPPs) are short sequences of amino acids that facilitate the penetration of conjugated cargoes across mammalian cell membranes, and as such, they may provide a safe and effective method for drug delivery to the inner ear. Simple polyarginine peptides have been shown to induce significantly higher cell penetration rates among CPPs. Herein, we show that a peptide consisting of nine arginines ("9R") effectively delivered enhanced green fluorescent protein (EGFP) into guinea pig cochleae via the round window niche without causing any deterioration in auditory function. A second application, 24 hours after the first, prolonged the presence of EGFP. To assess the feasibility of protein transduction using 9R-CPPs via the round window, we used "X-linked inhibitor of apoptosis protein" (XIAP) bonded to a 9R peptide (XIAP-9R). XIAP-9R treatment prior to acoustic trauma significantly reduced putative hearing loss and the number of apoptotic hair cells loss in the cochleae. Thus, the topical application of molecules fused to 9R-CPPs may be a simple and promising strategy for treating inner ear diseases.

Markers of Overall Nutritional Status and Incident Hearing Impairment in Community-Dwelling Older Japanese: The Kurabuchi Study

OBJECTIVES

To examine the association between four markers of overall nutritional status (a serum biomarker (albumin) and three anthropometric indices (body mass index (BMI), midarm circumference (MAC), calf circumference (CC))) and incident hearing impairment in older Japanese adults.

DESIGN

Community-based prospective cohort study.

SETTING

Kurabuchi Town, Gunma Prefecture, Japan.

PARTICIPANTS

Individuals aged 65 and older (143 men, 195 women) without hearing impairment at baseline examination (2005-06) who participated in repeated examinations 4 years later (2009-10) (N = 338).

MEASUREMENTS

The three anthropometric indices were measured at baseline, and nephelometry was used to assess serum albumin levels. Hearing impairment was defined as failure to hear a 30-dB hearing level signal at 1 kHz and a 40-dB signal at 4 kHz in the better ear on pure-tone audiometry.

RESULTS

Over the 4-year period, 16.3% of participants developed hearing impairment. Those with lower marker values had greater risk of hearing impairment than those with higher marker values (multivariable adjusted odds ratio (aOR) = 2.18, 95% confidence interval (CI) = 1.05-4.57 for albumin ≤4.0 g/dL; aOR = 2.72, 95% CI = 1.10-6.71 for BMI <19.0 kg/m(2) ). The pattern of association showed a similar tendency for MAC and CC. Excluding obese participants did not changed the results substantially.

CONCLUSION

Further research is needed to determine whether interventions that improve markers of nutritional status may help prevent age-related hearing loss in older adults.

Hyaluronic acid pretreatment for Sendai virus-mediated cochlear gene transfer

Gene therapy with viral vectors is one of the most promising strategies for sensorineural hearing loss. However, safe and effective administration of the viral vector into cochlear tissue is difficult because of the anatomical isolation of the cochlea. We investigated the efficiency and safety of round window membrane (RWM) application of Sendai virus, one of the most promising non-genotoxic vectors, after pretreatment with hyaluronic acid (HA) on the RWM to promote efficient viral translocation into the cochlea. Sendai virus expressing the green fluorescent protein reporter gene was detected throughout cochlear tissues following application combined with HA pretreatment. Quantitative analysis revealed that maximum expression was reached 3 days after treatment. The efficiency of transgene expression was several 100-fold greater with HA pretreatment than that without. Furthermore, unlike the conventional intracochlear delivery methods, this approach did not cause hearing loss. These findings reveal the potential utility of gene therapy with Sendai virus and HA for treatment of sensorineural hearing loss.

High prevalence of CDH23 mutations in patients with congenital high-frequency sporadic or recessively inherited hearing loss

BACKGROUND

Mutations in CDH23 are responsible for Usher syndrome 1D and recessive non-syndromic hearing loss. In this study, we revealed the prevalence of CDH23 mutations among patients with specific clinical characteristics.

METHODS

After excluding patients with GJB2 mutations and mitochondrial m.1555A > G and m.3243A > G mutations, subjects for CDH23 mutation analysis were selected according to the following criteria: 1) Sporadic or recessively inherited hearing loss 2) bilateral non-syndromic congenital hearing loss, 3) no cochlear malformation, 4) a poorer hearing level at high frequencies than at low frequencies, and 5) severe or profound hearing loss at higher frequencies.

RESULTS

Seventy-two subjects were selected from 621 consecutive probands who did not have environmental causes for their hearing loss. After direct sequencing, 13 of the 72 probands (18.1%) had homozygous or compound heterozygous CDH23 mutations. In total, we identified 16 CDH23 mutations, including five novel mutations. The 16 mutations included 12 missense, two frameshift, and two splice-site mutations.

CONCLUSIONS

These results revealed that CDH23 mutations are highly prevalent in patients with congenital high-frequency sporadic or recessively inherited hearing loss and that the mutation spectrum was diverse, indicating that patients with these clinical features merit genetic analysis.

Low-level laser therapy for prevention of noise-induced hearing loss in rats

Noninvasive low-level laser therapy (LLLT) is neuroprotective, but the mechanism of this effect is not fully understood. In this study, the use of LLLT as a novel treatment for noise-induced hearing loss (NIHL) is investigated. Sprague-Dawley rats were exposed to intense noise and their right ears were irradiated with an 808nm diode laser at an output power density of 110 or 165mW/cm(2) for a 30min period for 5 consecutive days. Measurement of the auditory brainstem response revealed an accelerated recovery of auditory function in the groups treated with LLLT compared with the non-treatment group at days 2, 4, 7 and 14 after noise exposure. Morphological observations also revealed a significantly higher outer hair cell survival rate in the LLLT groups. Immunohistochemical analyses for inducible nitric oxide synthase (iNOS) and cleaved caspase-3 were used to examine oxidative stress and apoptosis. Strong immunoreactivities were observed in the inner ear tissues of the non-treatment group, whereas these signals were decreased in the LLLT group at 165mW/cm(2) power density. Our findings suggest that LLLT has cytoprotective effects against NIHL via the inhibition of iNOS expression and apoptosis.

Spontaneous recovery of cochlear fibrocytes after severe degeneration caused by acute energy failure

Cochlear fibrocytes in the lateral wall region play a critical role in the regulation of inner ear ion and fluid homeostasis, although these are non-sensory cells. Along with other non-sensory cells, fibrocytes in the spiral ligament have been reported to repopulate themselves after damage. However, the studies of regeneration of cochlear fibrocytes have been difficult because a suitable fibrocyte-specific degeneration model did not exist. Therefore, we analyzed cochlear fibrocytes using a rat model of acute cochlear energy failure induced by a mitochondrial toxin. This model is unique because hearing loss is caused by apoptosis of fibrocytes in the cochlear lateral wall not by damage to sensory cells. Although this model involves severe damage to the cochlear lateral wall, delayed spontaneous regeneration occurs without any treatment. Moreover, partial hearing recovery is accompanied by morphological remodeling of the cochlear lateral wall. Two hypotheses are conceivable regarding this spontaneous recovery of cochlear fibrocytes. One is that residual cochlear fibrocytes proliferate spontaneously, followed by remodeling of the functional region of the lateral wall. Another is that some foreign cells such as bone marrow-derived cells promote morphological and functional recovery of the lateral wall. Acceleration of the lateral wall recovery promoted by these mechanisms may be a new therapeutic strategy against hearing loss.

Cricopharyngeal achalasia treated with myectomy and post-operative high-resolution manometry

Cricopharyngeal achalasia is an uncommon cause of dysphagia in neonates or children. A nine-year-old female patient was referred to us with a long history of dysphagia, recurrent pulmonary infection and growth stunting. A gastrostomy was introduced to improve her nutritional condition and to minimize potential inflammation in the pharynx. Subsequently, cervical cricopharyngeal myectomy was conducted. The surgical intervention allowed prompt resolution of symptoms without complications. High-resolution manometry post myectomy demonstrated a significant reduction in upper esophageal pressure together with proper relaxation at deglutition. The patient was able to consume solid food and liquid normally, and remained asymptomatic without medications six months after the surgery.

Age-related hearing loss and the factors determining continued usage of hearing aids among elderly community-dwelling residents

While hearing aids are recommended for people with age-related hearing loss, many with impaired hearing do not use them. In this study, we investigated how many elderly people in the study area needed hearing aids, and the factors that determined continued wearing of the devices. The study area was Kurabuchi Town, Japan, where 1,437 residents (those aged 65 years or over) were eligible for participation in the study; 1,414 participated, of whom, 103 (7.3%) were already using hearing aids at the start of the study. After the primary screening, hearing aids were lent to 68 participants (4.8%) who did not already have one, 38 of whom (60.3% of the borrowers, representing 2.7% of the total aged population) went on to wear the hearing aid continuously. The Hearing Handicap Inventory for the Elderly (HHIE) score was significantly elevated among these 38 participants. This study indicated that hearing aids are of potential benefit to many local residents. Multivariate logistic regression revealed that HHIE scores were associated with the extent of HA usage. The adjusted odds ratio for a 1-unit increase in HHIE score was 1.08 (95% confidence interval: 1.02–1.14). Programs like this, in which people with impaired hearing are identified at the local level and given appropriate assistance, are useful models for future use in societies with aging populations.

Tinnitus preceded depressive symptoms in community-dwelling older Japanese: a prospective cohort study

OBJECTIVE

Most studies of the association between tinnitus and depression have been cross-sectional, making it difficult to draw any conclusions about the directionality of the association. This study aimed to clarify whether tinnitus precedes the development of depressive symptoms in a general older population.

METHODS

Residents of Kurabuchi Town, Gunma Prefecture, Japan (239 men, 296 women: ≥65years) without depressive symptoms were given health examinations in 2005-2006. Information on tinnitus was obtained via a questionnaire. Depressive symptoms were then assessed in a face-to-face home visit interviews carried out once in 2007 and once in 2008 according to the Geriatric Depression Scale 15-item version (GDS15).

RESULTS

Among the men, the 2.5-year incidence of depressive symptoms (GDS15≥6) was higher in those with tinnitus than in those without (20.5% vs. 9.5%). In the multi-adjusted model, tinnitus was significantly associated with an increased risk of depressive symptoms (relative risk=2.07; 95% confidence interval=1.01-4.25). Among the women, no associations were found.

CONCLUSION

In the present study, tinnitus was independently associated with the risk of depressive symptoms developing in men, but not in women. We believe primary care providers and public health staff should recognize tinnitus as a risk factor for depressive symptoms.

Notch inhibition induces cochlear hair cell regeneration and recovery of hearing after acoustic trauma

Hearing loss due to damage to auditory hair cells is normally irreversible because mammalian hair cells do not regenerate. Here, we show that new hair cells can be induced and can cause partial recovery of hearing in ears damaged by noise trauma, when Notch signaling is inhibited by a γ-secretase inhibitor selected for potency in stimulating hair cell differentiation from inner ear stem cells in vitro. Hair cell generation resulted from an increase in the level of bHLH transcription factor Atoh1 in response to inhibition of Notch signaling. In vivo prospective labeling of Sox2-expressing cells with a Cre-lox system unambiguously demonstrated that hair cell generation resulted from transdifferentiation of supporting cells. Manipulating cell fate of cochlear sensory cells in vivo by pharmacological inhibition of Notch signaling is thus a potential therapeutic approach to the treatment of deafness.

A novel animal model of hearing loss caused by acute endoplasmic reticulum stress in the cochlea

Many stimuli such as ischemia, hypoxia, heat shock, amino acid starvation, and gene mutation, exhibit a cellular response called endoplasmic reticulum (ER) stress. ER stress induces expression of a series of genes, leading to cell survival or apoptosis. Previously, we found that in an animal model of hearing loss caused by acute mitochondrial dysfunction, several ER stress markers including C/EBP homologous protein were induced in the cochlear lateral wall. To elucidate the mechanism of hearing loss caused by ER stress, we established a novel animal model of hearing loss by perilymphatic perfusion of tunicamycin, an ER stress activator that inhibits N-acetylglucosamine transferases. Subacute and progressive hearing loss was observed at all sound frequencies studied, and stimulation of ER stress marker genes was noted in the cochlea. The outer hair cells were the most sensitive to ER stress in the cochlea. Electron microscopic analysis demonstrated degeneration of the subcellular organelles of the inner hair cells and nerve endings of the spiral ganglion cells. This newly established animal model of hearing loss from ER stress will provide additional insight into the mechanism of sensorineural hearing loss.

Balance dysfunction resulting from acute inner ear energy failure is caused primarily by vestibular hair cell damage

Inner ear energy failure is associated with disorders such as inner ear ischemia. Recently, we used the mitochondrial toxin 3-nitropropionic acid (3-NP) to establish an animal model of inner ear energy failure that presents with auditory dysfunction. Here we investigated the mechanisms underlying balance disorders in the 3-NP animal model. Spontaneous nystagmus peaked 6 hr after treatment with either 300 mM or 500 mM 3-NP. The nystagmus attenuated gradually and disappeared 3 days after 3-NP treatment. A caloric test using ice water was performed to evaluate residual vestibular function 7 days after 3-NP treatment. The response to caloric stimulation was reduced to approximately 40% of the response of the untreated ear following 300 mM 3-NP and was undetectable following 500 mM 3-NP. Structural changes in the peripheral vestibular organs were analyzed by light and electron microscopy. Severe loss of stereocilia was observed following 500 mM 3-NP, whereas disorganized and mildly reduced stereocilia were observed following 300 mM 3-NP. There was severe loss and degeneration of vestibular hair cells following 500 mM 3-NP but only slight loss and degeneration of hair cells following 300 mM 3-NP. These results indicate that acute inner ear energy failure causes balance dysfunction mainly by damaging hair cells in the vestibule, which is distinct from the mechanism underlying auditory disorders.

Prevalence and factors associated with tinnitus: a community-based study of Japanese elders

Background

The prevalence of tinnitus is reported to be high in older Western populations, and several risk factors have been suggested. However, community-based evidence on prevalence is limited and, to our knowledge, there is no such information from older non-Western populations. The purpose of this study was to determine the prevalence and factors associated with tinnitus in community-dwelling Japanese elders.

Methods

In this community-based cross-sectional study, 1320 residents of Kurabuchi Town aged 65 years or older (584 men and 736 women; participation proportion = 98.7%) were interviewed at home in 2006, and information on tinnitus and factors associated with tinnitus was collected. We estimated the prevalence of tinnitus by age group and sex and used a logistic regression model to investigate associated factors.

Results

The prevalence of tinnitus was 18.6% (men: 18.0%; women: 19.0%); there were no statistically significant differences by age group or sex. Hearing difficulty, depressive mood, prescribed medication, past/current history of coronary heart disease, and knee joint pain requiring medical consultation were associated with tinnitus.

Conclusions

These findings suggest that tinnitus is common in Japanese aged over 65 years. Because the factors associated with tinnitus in this cross-sectional study are potentially modifiable, they should be thoroughly investigated in a longitudinal study.

Enhanced expression of C/EBP homologous protein (CHOP) precedes degeneration of fibrocytes in the lateral wall after acute cochlear mitochondrial dysfunction induced by 3-nitropropionic acid

We previously reported that treatment of the rat cochlea with a mitochondrial toxin, 3-nitropropionic acid (3-NP), causes temporary to permanent hearing loss depending on the amount of the drug. Furthermore, apoptosis of cochlear lateral wall fibrocytes, which are important for maintaining the endolymph, is a predominant pathological feature in this animal model. 3-NP is known to induce oxidative stress as well as neuronal apoptosis. C/EBP homologous protein gene (chop) is one of the marker genes induced during endoplasmic reticulum (ER) stress, and is also considered to be involved in apoptosis. To elucidate the molecular mechanism of cochlear fibrocyte apoptosis induced by 3-NP, we studied spatiotemporal expression of C/EBP homologous protein (CHOP) and other signaling molecules related to ER stress as well as the appearance of apoptotic cells in the cochlear lateral wall after 3-NP treatment. Quantitative real-time PCR revealed that chop and activating transcription factor 4 gene (atf-4) showed marked increase within 6h, whereas expression of other ER stress-responsive genes such as grp78 and grp94 did not change. Immunohistochemistry showed that 3-NP treatment caused up-regulation of CHOP, especially in type II and type IV fibrocytes, followed by the appearance of terminal deoxynucleotidyl transferase mediated dUTP nick end-labeling (TUNEL)-positive apoptotic cells in the same confined area. Thus, apoptosis of lateral wall fibrocytes induced by 3-NP is likely to be mediated by induction of CHOP. These results contribute clarification of pathological mechanism of cochlear fibrocytes and may lead to development of novel therapeutic strategy for hearing loss.

Gender-specific associations of vision and hearing impairments with adverse health outcomes in older Japanese: a population-based cohort study

Background

Several epidemiological studies have shown that self-reported vision and hearing impairments are associated with adverse health outcomes (AHOs) in older populations; however, few studies have used objective sensory measurements or investigated the role of gender in this association. Therefore, we examined the association of vision and hearing impairments (as measured by objective methods) with AHOs (dependence in activities of daily living or death), and whether this association differed by gender.

Methods

From 2005 to 2006, a total of 801 residents (337 men and 464 women) aged 65 years or older of Kurabuchi Town, Gunma, Japan, participated in a baseline examination that included vision and hearing assessments; they were followed up through September 2008. Vision impairment was defined as a corrected visual acuity of worse than 0.5 (logMAR = 0.3) in the better eye, and hearing impairment was defined as a failure to hear a 30 dB hearing level signal at 1 kHz in the better ear. Information on outcomes was obtained from the town hall and through face-to-face home visit interviews. We calculated the risk ratios (RRs) of AHOs for vision and hearing impairments according to gender.

Results

During a mean follow-up period of 3 years, 34 men (10.1%) and 52 women (11.3%) had AHOs. In both genders, vision impairment was related to an elevated risk of AHOs (multi-adjusted RR for men and women together = 1.60, 95% CI = 1.05-2.44), with no statistically significant interaction between the genders. In contrast, a significant association between hearing impairment and AHOs (multi-adjusted RR = 3.10, 95% CI = 1.43-6.72) was found only in the men.

Conclusion

In this older Japanese population, sensory impairments were clearly associated with AHOs, and the association appeared to vary according to gender. Gender-specific associations between sensory impairments and AHOs warrant further investigation.

Caspase inhibitor facilitates recovery of hearing by protecting the cochlear lateral wall from acute cochlear mitochondrial dysfunction

We recently showed that acute energy failure in the rat cochlea induced by local administration of the mitochondrial toxin 3-nitropropionic acid (3-NP) causes hearing loss mainly due to degeneration of cochlear lateral-wall fibrocytes. In the present study, we analyzed the effect of the pan-caspase inhibitor z-Val-Ala-Asp(Ome)-fluoromethylketone (Z-VAD-FMK) on 3-NP-induced hearing loss in a model showing temporary threshold shifts at low frequencies and permanent threshold shifts at high frequencies. The model rats received an intraperitoneal injection of either Z-VAD-FMK or vehicle for 3 days starting 1 day prior to 3-NP treatment. One day after the administration of 3-NP, the auditory brain-stem response (ABR) threshold at 20 kHz was elevated to 70 dB in the Z-VAD-FMK group and to 85 dB in controls. The Z-VAD-FMK group completely recovered to the preoperative level within 14 days, whereas in the controls, the ABR threshold remained elevated at 50 dB even 28 days after the administration of 3-NP. Treatment with Z-VAD-FMK also improved recovery of hearing at 8 kHz but did not change recovery at 40 kHz. Histological examination demonstrated that treatment with Z-VAD-FMK inhibited progressive degeneration of the lateral-wall fibrocytes in the cochlear basal turn, as well as apoptosis of these fibrocytes. These results clearly indicate that caspase-dependent apoptosis of fibrocytes in the cochlear lateral wall plays an important role in hearing loss in the present animal model. Moreover, the results of the present study suggest that systemic administration of a caspase inhibitor may be an effective therapy for sensorineural hearing loss caused by acute energy failure such as that observed in cochlear ischemia.

Pulse-oximetery is useful in determining the indications for adeno-tonsillectomy in pediatric sleep-disordered breathing

OBJECTIVE

Although first line therapy of sleep-disordered breathing (SDB) in children is adeno-tonsillectomy, the indications for this operation have not yet been clearly established. We investigated whether pulse-oximetry is useful for determining the optional treatment modality for pediatric SDB.

METHOD

Two hundred and thirty-two children presenting with snoring and gasping had their oxygen saturation levels examined during sleep. Among them, 86 underwent on adeno-tonsillectomy and were evaluated pre- and post-surgery. We also examined 25 healthy children as controls.

RESULTS

Little desaturation was observed in healthy children. The difference in oxygen saturation levels of the patients between pre- and post-surgery was closely correlated with the pre-surgery levels. We examined the reaction operation characteristics and concluded that children with an oxygen desaturation index of 4% or more (ODI4) of more than 1.5 and/or ODI3 of more than 3.5 should undergo surgery.

CONCLUSION

Pulse-oximetry is useful in determining the indications for adeno-tonsillectomy.

Oncocytic carcinoma in the submandibular gland: report of a case based on anti-mitochondrial immunohistochemical observations

Oncocytic carcinoma arising in the submandibular gland is a very rare tumor that has only previously been reported in nine cases. This paper describes an additional case of oncocytic carcinoma in the right submandibular gland. The patient was a 55-year-old Japanese male who was presented with a 3 cm right submandibular mass. Both radical resection of the tumor and right supraomohyoid neck dissection were performed. Histologically, the tumor cells exhibited an abundant eosinophilic cytoplasm, which appeared to be finely granular, and invaded the surrounding tissues. In addition, perineural invasion was also observed. Electron microscopy demonstrated the presence of an abundance mitochondria in the cytoplasm of the tumor cells. However, since the fine structure of cytoplasm was destroyed by fixation and embedding of the tissue for the light microscopy, the cytoplasm of the tumor could not be observed clearly. Immunohistochemically, anti-mitochondrial antibody positivity was evident in the cytoplasm of the tumor cells. Consequently, we diagnosed the mass as oncocytic carcinoma. Usually, electron microscopy is necessary to diagnose oncocytic lesions, but the paraffin-embedded tissue was not suitable for electron microscopy. Immunohistochemistry using an anti-mitochondrial antibody was found to be useful and helpful for the diagnosis of oncocytic lesions.

Aphonia and dysphagia after gastrectomy

A 67-year-old male was referred to our otolaryngological clinic because of aphonia and dysphagia. His voice was breathy and he could not even swallow saliva following a total gastrectomy for gastric carcinoma performed 2 weeks previously. Laryngeal fiberscopy revealed major glottal incompetence when he tried to phonate. However, both vocal folds abducted over the full range during inhalation. The patient could not swallow saliva because of a huge glottal chink, even during phonation. Based on these findings, he was diagnosed as having bilateral incomplete cricoarytenoid dislocation after intubation. The patient underwent speech therapy; within 1 min his vocal fold movement recovered dramatically and he was able to phonate and swallow. There have been few case reports of bilateral cricoarytenoid dislocation, and no effective rehabilitation has been reported. We believe that our method of vocal rehabilitation serves as a useful reference for physicians and surgeons worldwide.

[Review of 26 patients operated on for primary hyperparathyroidism]

The traditional surgical approach for primary hyperparathyroidism (PHP) is routine bilateral neck exploration. At Saiseikai Utsunomiya Hospital, however, unilateral exploration, and the direct resection of one gland is performed if single gland enlargement is suspected, based on the findings of several preoperative localization procedures. Here, we reviewed 26 patients who underwent single gland operations for PHP at our institution between 1993 and 2001. The 26 patients (21 women and 5 men) ranged in age from 20 to 79 years (mean, 54.8 years). None of the patients had multiple endocrine neoplasia (MEN), familial hypercalcemia, or malignant tumors. At least three preoperative localization procedures, such as ultrasonography, computed tomography, thallium technetium scanning, 99mTc sestamibi scintigraphy, or magnetic resonance imaging, were performed in each patient. A parathyroidectomy was then performed under general anesthesia. Contralateral exploration was not routinely performed. In addition, an intraoperative biopsy of the other glands was not performed. The following data were retrospectively collected in all patients: serum calcium, and the HS-PTH at one month and 6 months after the parathyroidectomy. All patients were normocalcemic, and the serum HS-PTH concentration significantly decreased in all patients after this operation. Patients were divided into two groups (adenoma group, n = 16; hyperplasia group, n = 6) and the data was analyzed according to the histological and pathological diagnosis. In both pathological groups, all patients were normocalcemic and the serum HS-PTH concentration was significantly lower after surgery. The serum HS-PTH concentration showed no significant difference between the adenoma group and the hyperplasia group at 6 months after surgery. No complications, including recurrent laryngeal nerve palsy or permanent hypocalcemia, were observed after surgery. In conclusion, if a single gland disease is suspected based on the findings of multiple preoperative localization procedures, resection of the enlarged gland alone appears to provide good results for the treatment of either adenoma or hyperplasia resulting in PHP. In addition, this procedure also reduces the occurrence of postoperative hypocalcemia, because the normal glands are not injured by the biopsy procedures.

[Nocturnal pulse oximetry diagnosis for screening pediatric obstructive sleep apnea syndrome]

We evaluated the diagnostic value of pulse oximetry during sleep in pediatric obstructive sleep apnea syndrome (OSAS) caused by adenoid-tonsil hypertrophy. Subjects were 22 healthy children free of symptoms such as snoring, sleep apnea and oral breathing and 163 children suspected of OSAS with snoring or sleep apnea. Subjects were measured for percutaneous oxygen saturation (SpO2) during sleep. Of those with suspected OSAS, 69 underwent adenotonsillectomy and were measured for SpO2, both pre- and postoperatively, then pre- and postoperative measurements were compared. After measurement, we analyzed three parameters: lowest saturation (LSpO2), the desaturation index, and total desaturation duration under 95% (TDD95). Few abnormal findings were seen in healthy children. We calculated the mean and standard deviation (SD) of each parameter and set borderlines of mean-2SD for LSpO2 and mean + 2SD for ODI and TDD95. With these borderlines, 105 children for LSpO2, 75 for ODI and 76 for TDD 95 were judged to be normal among the 163 with suspected OSAS. Histograms showed that the mode of each parameter was situated near the borderline. Comparison between pre- and postoperative measurements showed that the effect of the surgery strongly correlated with preoperative measurement in patients undergoing surgery. Assuming that a patient with postoperative improvement is positive, we calculated sensitivity and specificity for each borderline measurement. We found that if success is 100%, the borderline should be 87% for LSpO2, 3.5 for ODI, and 30.0 for TDD95. If success exceeds 90%, the borderline should be 90% for LSpO2, 2.0 for ODI, and 7.0 for TDD95. We therefore conclude that measurement of SpO2 during sleep is useful in screening for pediatric OSAS.

Cutaneous mucormycosis

The patient, a 59-year-old male, had been diagnosed as having alcoholic hepatopathy 20 years previously. He noticed localized swelling on his left leg after fishing in a river. The patient was diagnosed as having cutaneous mucormycosis upon histological and mycological examination of the skin. Gradual improvement of the symptoms was noted four weeks after administration of itraconazole and fruconazole; these were discontinued after five months.

Clinical phenotype of Bart's syndrome seen in a family with dominant dystrophic epidermolysis bullosa

BACKGROUND

Bart's syndrome is one type of dominant dystrophic epidermolysis bullosa (EB). It is known that, in some familial cases of dominant dystrophic EB, the symptoms differ depending on the individual. We observed the way Bart's syndrome affected four generations in the same family. The proband was a newborn boy who showed congenital localized absence of skin (CLAS) and bullae on the anterior aspects of both legs. Histologically, the bullae were located subepidermally. The CLAS and bullae disappeared within 4 months after birth, leaving scars. His father retained scarring and scaling from the knees down along the anterior aspect of the legs, and the nails of the toes were either lacking or deformed. His paternal grandmother and great-grandmother also presented deformed nails of the toes, although they had not had CLAS or bullae on the legs at birth. The individuals in this family thus showed some heterogeneity depending on the sex: blistering and CLAS were seen on the legs soon after birth in the male family members, but the female members did not share this pattern of symptoms, suggesting that the expression of symptoms may differ depending on the sex of the affected individual.

Photo-enhanced modification of human skin elastin in actinic elastosis by N(epsilon)-(carboxymethyl)lysine, one of the glycoxidation products of the Maillard reaction

Long-term incubation of proteins with glucose leads to the formation of advanced glycation end products (AGEs), which are characterized by fluorescence, brown color, and cross-linking. Formation of AGEs in vitro requires oxygen and is dependent on transition metal-catalyzed oxidation of glucose or Amadori products. AGEs are thought to be involved in aging and age-enhanced diseases such as diabetic complications, atherosclerosis, dialysis-related amyloidosis, and Alzheimer's disease. Chronic exposure of the skin to sunlight induces hyperplasia of the elastic tissue in the upper dermis known as actinic elastosis. Herein we used a monoclonal anti-AGE antibody (6D12) whose epitope is N(epsilon)-(carboxymethyl)lysine (CML), one of the glycoxidation products of AGEs, and demonstrated that the lesions of actinic elastosis were modified by CML. Further immunohistochemical and immunoelectron microscopic examination with 6D12 demonstrated CML accumulates predominantly in elastic fibers especially in the amorphous electron-dense materials corresponding to photo-induced degenerated area rather than the electron-lucent region. Immunochemical analyses with enzyme-linked immunosorbent assay (ELISA) of elastase-soluble fractions demonstrated that the CML levels of the sun-exposed area were significantly higher than those of the sun-unexposed area. We conclude that ultraviolet-induced oxidation may accelerate CML formation in actinic elastosis of photoaged skin.

Immediate allergy to rubber gloves: a questionnaire study of hospital personnel

We conducted a questionnaire study of immediate allergy to natural rubber gloves among 2,408 medical workers who had used rubber gloves at Kumamoto University Hospital and allied hospitals. The response rate was 64.5% (1,321 workers). Among them, 8.5% (7.0-10.0% at 95% confidence limit) replied that they had experienced immediate allergy to rubber gloves. There were significant correlations among the frequency of rubber glove use, a history of atopic dermatitis or contact dermatitis, and the presence of skin lesions due to allergic reactions to rubber gloves. In 27 workers, skin lesions were associated with general symptoms. Of 59 workers who experienced immediate allergy and were tested for latex-specific IgE, 4 persons were positive. We conclude that the frequency of contact allergy to natural rubber products is substantially prevalent among Japanese hospital personnel and that education and awareness of this allergy are important.

Synthesis and antihypertensive activity of 3-acetoxy-2,3-dihydro-5-[2- (dimethylamino)ethyl]-2-(4-methoxyphenyl)-1,5-benzothiazepin-4(5H)-one (diltiazem) derivatives having substituents at the 8 position

In order to improve the potency and duration of biological actions of diltiazem, a number of 1,5-benzothiazepine derivatives having the substituents at the 8 position were prepared and evaluated for their antihypertensive activity in spontaneously hypertensive rats. The introduction of methyl, ethyl, isopropyl, benzyl, methoxy, ethoxy, phenoxy, and methylthio groups increased the antihypertensive activity and prolonged duration of action, whereas cyclohexyl, cyclopentoxy, tolyloxy, p-methoxyphenoxy and phenylthio derivatives were less active than diltiazem. Among them, the 8-benzyl and phenoxy derivatives showed the most potent and long-lasting antihypertensive action.

Morphea profunda--a cutaneo-pulmonary variant with profuse sweating

A 51-year-old Japanese male developed morphea profunda over a plaque of pigmented sweating skin on the left chest extending deeply into the lung. Eight years previously, he noted a brown pigmented spot on the left axilla which started to enlarge over the left chest in a band-like manner. Later, the involved skin hardened with profuse sweating. Chest X-ray examination and computer tomography revealed a thickening of the left chest wall and a nodular mass lesion in the left lower lung field. Biopsy specimens from lung, chest wall, and overlying skin revealed a granulomatous tissue in the parenchyma and a marked fibrosis extending from the deep dermis to the pleura. There were no findings suggestive of malignancy or chronic infectious disease. We assume that the process of morphea in this patient extended deeply from the skin to the lung.