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105 巻, 4 号
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論説
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―行動工学的手法を用いた手術手技・能力の評価と指導―友田 幸一, 村田 英之, 馬場 一泰, 朝子 幹也, 山下 樹里原稿種別: 論説
2012 年 105 巻 4 号 p. 293-301
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありWe present a step-up training system for endonasal endoscopic surgery based on the evaluation by the trainers and self-assessments.
Step 1: The trainees are taught basic anatomy and the pre-operative planning. The navigation system is useful in this step.
Step 2: We developed a surgical skill training system (HyperMirror interface). We analyzed the difference of a handling of surgical instruments, a loading force, and invasiveness between trainees and trainers using a precise nasal model. In easy tasks, the surgical time got comparable between the trainees and trainers after the repeated training. In difficult tasks, however, the surgical time depended on personal ability, and simple repeated training was not enough to improve the surgical time. Large difference was found between the trainees and trainers in the force power of the instruments to a model and the range of bone dissection. Using a precise nasal model and a navigation system, it was possible to compare endoscopic view and macroscopic observation in a three-dimensional manner.
Step 3: In the operation theater, the instructor do the surgery using a precise nasal model made on the patients’ own CT scan. The trainees can learn the safe / precise operation by following the surgical field made by the instructor using a model.
To improve the quality of surgery education, it will be necessary to evaluate an ability of instructors and the mental load of trainees. Finally, we hope to develop a new educational program that every trainee can learn standard surgical techniques efficiently.
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カラー図説
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加藤 久幸原稿種別: カラー図説
2012 年 105 巻 4 号 p. 302-303
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありPDF形式でダウンロード (1065K)
臨床
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佐伯 忠彦, 大河内 喜久, 渡辺 太志原稿種別: 臨床
2012 年 105 巻 4 号 p. 305-313
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありWe investigated 211 inpatients in our hospital who underwent treatment within 2 weeks of the onset of idiopathic sudden sensorineural hearing loss over an eight year-period (January 2003 to December 2010). Some prognostic factors analyzed in this study were as follows; age, sex, side, smoking, the initial averaged five-frequency hearing level, grade, vestibular symptom, complications such as diabetes mellitus (DM) and hypertension (HT), and the period to fixation of hearing level.
The ages of patients ranged from 10 to 85 years (median 56.5 yr). Males and females accounted for 106 and 105 cases, respectively. The sides of hearing impairment were 105 in the right, 105 in the left and 1 in the bilateral ears. The smoking rate of our cases was lower than that of the general population as reported by the Ministry of Health, Labour and Welfare. The main hearing types were horizontal and deaf before treatment, and high-frequency impairment and normal hearing after treatment. The overall results of the treatment showed 87 (41.0%) patients with a complete recovery, 53 (25.0%) with a marked improvement, 40 (18.9%) with some improvement and 32 (15.1%) with no change. Hearing improvement of 4000 Hz was worse than those of 250, 500 and 1000 Hz. Hearing improvement was good in the valley and low tone senseorineural hearing loss types, on the other hand, it was worst in the deaf type. Hearing improvement of Grade 4 was worse than those of Grade 1, 2 and 3. Smoking and DM had no influence on the prognosis. The complete recovery rate of those over 60 years of age was worse than in those under 60 years of age. The prognoses of patients with vestibular symptom and HT were worse than those without them.
Important prognostic factors strongly related to the complete recovery rate were the presence of vertigo and the grade of initial hearing level as determined by multiple logistic regression analyses. The period to fixation of hearing level in Grade 4 was prolonged as compared with those of Grade 1, 2 and 3. We recommend to follow up for two weeks in Grade 1, two months in Grade 2 and 3, and six months in Grade 4 to obtain an accurate evaluation of hearing improvement.
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西田 明子, 金井 理絵, 田村 芳寛, 辻 拓也, 窪島 史子, 山本 季来, 前谷 俊樹, 金丸 眞一2012 年 105 巻 4 号 p. 315-322
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありWe report on two cases of auditory ossicular anomaly and one case of traumatic ossicular dislocation evaluated with three-dimensional images using MDCT (multidetector-row CT). The first patient was an 18-year-old female, who had noticed hearing impairment in her right ear since she was a child. The second patient was a 32-year-old male, complaining of hearing loss in his right ear after a head injury. The third patient was a 27-year-old female who had hearing impairment in her right ear probably from birth. The first and the second patients underwent surgery, and their congenital ossicular anomaly and traumatic ossicular disarticulation were identified intraoperatively, which were almost corresponding to the findings shown by three-dimensional computed tomography (3D-CT). In both cases, the additional information provided by 3D-CT, together with conventional cross-sectional CT images, improved the ability to evaluate and diagnose the auditory ossicular lesions preoperatively. Although the third patient did not undergo surgery because she preferred observation, 3D-CT clearly showed the abnormality of her ossicles compared with conventional CT images, which helped her and her family to understand the reason for her hearing impairment. Our cases indicate that 3D-CT is useful not only for surgeons to optimize surgical planning but also for patients to understand the condition of their middle ear.
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武藤 俊彦, 児島 雄介, 橋本 健吾, 塩田 絵里子, 樫葉 恵子2012 年 105 巻 4 号 p. 323-329
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありAmong complications associated with tympanostomy tube insertion, intrusion of the tube into the tympanic cavity is very rare. We experienced 4 cases in which extraction of the tympanostomy tube was required because of intrusion into the tympanic cavity. Recurrent otitis media accounted for 2 cases, and otitis media with effusion for the other 2. General anesthesia was required in 3 cases for extracting the tubes. Endoscopy was effective for tube extraction in all cases.
We obtained information by means of a questionnaire concerning tympanostomy tube insertion from 68 otolaryngologists. In this questionnaire, the most common incident was perforation of the tympanic membrane, and the next most common incident was intrusion of the tube into the tympanic cavity. Two cases were settled out of court, both of which involved tube intrusion into the tympanic cavity.
Intrusion of the tube into the tympanic cavity might have occurred due to an early incident such as a large myringotomy incision, a delayed incident such as centrifugal migration of the epithelium leading to pressure in the tympanic cavity, or persistent negative middle ear pressure. Among the reported cases, 3 cases had a large myringotomy incision and 1 case experienced a delayed incident.
The intruded tube should be removed as soon as possible. However, it is necessary to explain the opinion of the previous surgeon to the patients to maintain the surgeon-patient relationship.
Informed consent, including the possibility of tube intrusion into the tympanic cavity, the method of tube extraction, and other tube-related complication in the tympanic cavity during tympanostomy tube insertion, should be obtained.
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佐藤 達明2012 年 105 巻 4 号 p. 331-337
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありAllergic rhinitis, especially Japanese cedar pollinosis, is a major problem in Japan. Recent research has revealed that the symptoms of allergic rhinitis are aggravated after the Asian sand dust (ASD) phenomenon which tends to occur concomitantly with the pollen season in Japan.
Objectives: A questionnaire survey was conducted to investigate whether ASD is recognized as a factor which affects human health, and whether people are interested in information about the ASD phenomenon. The questionnaire survey was undertaken in cooperation with otolaryngologists in the eastern area of Shimane prefecture.
Results: Three hundred and seventy-seven volunteers including 288 patients with allergic rhinitis and 89 without allergic rhinitis were enrolled. Two hundred and seventy-six of the 377 volunteers (73.2%) recognized ASD as a factor which may affect human health and 150 of the 377 volunteers felt that their own health condition changed after the ASD phenomenon. As symptoms, in addition to nasal symptoms, other symptoms such as sore throat, abnormal sensation, cough and eye symptoms developed in volunteers with/without allergic rhinitis. Two hundred and ninety-seven of the 377 volunteers answered that they were interested in information about ASD, such as the relationship between allergic rhinitis and ASD.
Conclusion: The results of this survey suggest that clinicians who treat allergic diseases need to collect and provide information on not only pollen but also the ASD phenomenon for patients, especially those who have allergic rhinitis, to help them to maintain a good quality of life.
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橋田 光一, 寳地 信介, 大久保 淳一, 今里 圭, 池嵜 祥司, 田畑 貴久, 鈴木 秀明2012 年 105 巻 4 号 p. 339-343
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありThe nasopharyngeal flora is generally thought to be a major reservoir for bacterial pathogens of respiratory tract infections in children. We surveyed the bacterial flora in the nasopharynx of 261 outpatients aged 0 to 6 yeas who visited the Department of Otorhinolaryngology and/or Pediatrics from 2005 through 2010. We obtained 118 Haemophilus influenzae (H. influenzae) isolates, 116 Streptococcus pneumoniae (S. pneumoniae) isolates, 44 Staphylococcus aureus (S. aureus) isolates, and 40 Moraxella catarrhalis isolates, and analyzed them by antibiotic susceptibility testing. The overall carriage rates of the H. influenzae strains and S. pneumoniae strains were 45.2% (118/261) and 44.4% (116/261), respectively. The percentages of ampicillin-resistant H. influenzae strains, penicillin-resistant S. pneumoniae strains and methicillin-resistant S. aureus were 80.5% (95/118), 55.2% (64/116) and 40.9% (18/44), respectively. The H. influenzae strain was susceptible to cefditren pivoxil, minocycline, and levofloxacin, while the S. pneumoniae strain was susceptible to cefditren pivoxil, cefotaxime sodium, and panipenem/betamipron. The percentage of ampicillin-resistant H. influenzae strains was invariably high in all years. On the other hand, the percentage of penicillin-resistant S. pneumoniae strains was highest in 2008, and gradually decreased after that. The recovery of susceptibility to penicillin in clinical isolates of S. pneumoniae may reflect recent enlightenment in the appropriate use of antimicrobial drugs.
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本間 博友, 八尾 亨, 斉藤 達矢, 楠 威志, 池田 勝久2012 年 105 巻 4 号 p. 345-349
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありDespite being minimally invasive, the endonasal approach to inflammatory frontal sinus disease may present problems. Previously, prevalent external frontal surgery and osteogenic inflammatory frontal sinus processes often involved difficult access to or stenosis of the frontal sinus outflow tract. We present 6 cases of intractable inflammatory frontal sinus disease and discuss surgical approaches. Subjects were 4 men and 2 women 27 to 74 years old. The 5 cases of recurrent frontal sinus disease required Draf type II drainage or an endoscopic modified Lothrop procedure (EMLP) with or without stenting. The 1 case of frequently recurring inflammatory fontal sinus lesions with a markedly ossified frontal sinus outflow tract required the obliteration of fatty tissue. None of our cases showed recurrence after a relatively short follow-up of less than 5 years. Despite the relatively small case number and short follow-up, our results suggest that recurrent and extensive inflammatory frontal sinus lesions require tailor-made treatment using both endoscopic and external approaches.
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山原 康平, 隈部 洋平, 田中 信三, 平塚 康之, 和田 忠彦, 山田 光一郎2012 年 105 巻 4 号 p. 351-356
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありIntramusucular hemangioma is a benign neoplasm frequently arising from the skeletal muscles of the trunk and extremities.
Involvement of the head and neck by this tumor is rare, even though the majority of such tumors originate from the masseter and the trapezius. Preoperative diagnosis is very difficult because of the rarity and the distribution of these tumors in the deep space. We report on a rare case of intramuscular hemangioma, involving the posterior cricoarytenoid muscle. A 82-year-old female patient with an abnormal sensation in her throat, was found to have a tumor in the left piriform sinus. Thus we performed biopsies twice, but the pathology was not confirmed, with a report of just normal mucosa. However we speculated that the tumor was benign and so performed a lateral neck exploration. The tumor was completely removed. Histological examination revealed it to be an intramuscular hemangioma of the skeletal muscle. Based on the intraoperative findings of the tumor, we diagnosed it as an intramuscular hemanginoma originating from the posterior cricoarytenoid muscle. As the posterior cricoarytenoid muscle opens the glottal space, the left vocal cord was fixed medially after the surgery. Nevertheless its tonus appeared fine and phonetic function remained normal.
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前田 秀典, 竹中 幸則, 喜井 正士, 猪原 秀典2012 年 105 巻 4 号 p. 357-361
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありCarcinoma showing thymus-like differentiation (CASTLE) is a rare malignant neoplasm that occurs in the thyroid gland. We report on a case of CASTLE which was difficult to diagnose. A 53-year-old male with hoarseness and dyspnea was referred to our department. Fine needle aspiration biopsy suggested malignant lymphoma of the thyroid gland. Subsequent open biopsy revealed a definite diagnosis of CASTLE. We performed a total thyroidectomy, paratracheal neck dissection and partial resection of the trachea. The patient’s post-operative course was uneventful and there have been no signs of recurrence since surgery.
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上田 奈津子, 水田 啓介, 加藤 久和, 青木 光広, 伊藤 八次2012 年 105 巻 4 号 p. 363-367
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありWe report the case of an 87-year-old woman with sternal bone metastasis and multiple lung metastases from thyroid cancer who underwent hemithyroidectomy, then noticed anterior chest swelling. Chest CT showed a mass destroying the upper sternum. As the anterior chest mass grew, CT showed an increasingly large tumor, suggesting expansion to the anterior mediastinum. The size of multiple lung nodules, however, was unchanged from the previous scan. Suspecting the tumor of causing the woman's discomfort, we partially resected the sternum and reconstructed the sternal defect using a major myocutaneous pectoral flap. She has had no physical or pulmonary impairment since.
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松尾 美央子, 力丸 文秀, 檜垣 雄一郎2012 年 105 巻 4 号 p. 369-373
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありTS-1® is an oral anticancer drug composed of tegafur which is a derivative of 5FU and 5-chloro-2,4-dihydroxypyridine (CDHP) and oxonic acid. We report on a patient with acute toxicosis who orally ingested a large dose of TS-1® 1400 mg in an effort to commit suicide.
First of all, we treated him with gastric lavage, laxative and hydration. After that, he underwent hemodialysis. Before hemodialysis the blood concentration of tegafur was 25200 ng/mL, 5-FU was 3000 ng/mL and CDHP was 1870 ng/mL. These blood concentrations were high, compared with cases where 50 mg of TS-1® has been ingested. After the 2nd hemodialysis, all blood concentrations decreased to the normal level, so the patient was saved without severe side effects. To our knowledge, there has been no report of a case involving ingestion of a large dose of TS-1®, and we therefore report our experience of this rare case.
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薬物
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松田 和徳, 川田 育二, 阿部 律子, 北村 嘉章, 関根 和教, 阿部 晃治, 田村 公一, 武田 憲昭原稿種別: 薬物
2012 年 105 巻 4 号 p. 375-379
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありWe examined the effect of oral administration of beraprost sodium, a derivative of prostaglandin I2 (PGI2) in patients with sudden deafness as a salvage treatment after failure of initial systemic steroid therapy with prostaglandin E1. We then compared them with those of mecobalamin, a derivative of vitamin B12. A significant improvement in the average hearing level was obtained in patients who received beraprost sodium for 12 weeks, but not in patients who received mecobalamin. The hearing levels at 125 Hz, 250 Hz, 500 Hz and 8000 Hz significantly improved after the salvage treatment of beraprost sodium over those of mecobalamin. These findings suggested that oral administration of the PGI2 derivative could be utilized as a salvage treatment for refractory sudden deafness after failure of initial steroid therapy.
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山中 昇, 杉田 麟也, 宇野 芳史, 松原 茂規, 林 泰弘, 澤田 正一2012 年 105 巻 4 号 p. 381-392
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありSpecial attention has been focused on the recent problem of pediatric acute otitis media. The increase in the number of pediatric patients with intractable acute otitis media has been a serious problem in the clinical setting of ENT clinics and hospitals. Such a change in the clinical figures of otitis media may be due to the social environment, including the tendency for more very young children to be looked after at nurseries, and the increase in drug-resistant bacteria. In the clinical guidelines for the treatment of pediatric acute otitis media, published in 2006 and revised in 2009, a classification of severity according to scoring of symptoms and tympanic membrane findings was proposed and a severity-oriented treatment algorithm was recommended. In response to the proliferation of drug-resistant bacteria, we have also emphasized the importance of the proper use of antimicrobials and have promoted a correct assessment of the clinical efficacy of various antimicrobial agents according to the scoring system recommended by the guidelines. In this study, we employed this severity classification by the scoring system to examine the usefulness and bacteriological efficacy of tosufloxacin (TFLX) fine granules (6 mg/kg bid), a novel pediatric quinolone antimicrobial, in 106 children aged 15 or under diagnosed with moderate or severe acute pediatric otitis media. We obtained the following results. The clinical response rate to TFLX was 98.1% (104/106) according to the score-oriented evaluation and 97.2% (103/106) as conventionally judged by the treating physicians. Bacterial pathogens detected in this study were Haemophilus influenzae 37.7% (40/106), Streptococcus pneumoniae 32.1% (34/106) and Moraxella catarrhalis 6.6% (7/106). At the time of completion of TFLX administration, the rate of bacterial elimination was 95.8% (69/72). Only one patient experienced mild diarrhea as an adverse drug reaction.
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総説
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石川 征司, 楯谷 一郎, 平野 滋, 伊藤 壽一原稿種別: 総説
2012 年 105 巻 4 号 p. 393-402
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありHead and neck squamous cell carcinoma (HNSCC) is globally the seventh most common cancer. Its 40–50% 5-year survival rate has not improved significantly in the last decade despite surgical, radiotherapy and chemotherapy progress. Significantly increased knowledge of biomarkers and molecular biology of HNSCC has shown that smoking and alcohol consumption cause HNSCC and that the human papilloma virus (HPV) is related to HNSCC oncogenesis. Tumor/node/metastasis (TNM) staging is essential to determining treatment and prognosis. Even early-stage subjects may have recurrence and/or distant metastasis. New biomarkers should provide new categories and staging determing prognosis preoperatively by routine tumor biopsy that, in turn, will improve HNSCC management. Here we review molecular biology of HNSCC and discuss potential analysis and treatment.
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研修ノート
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平海 晴一原稿種別: 研修ノート
2012 年 105 巻 4 号 p. 404-405
発行日: 2012年
公開日: 2012/04/01
ジャーナル 認証ありPDF形式でダウンロード (743K)
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