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106 巻, 7 号
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論説
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池田 勝久2013 年 106 巻 7 号 p. 573-580
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありAlthough chronic rhinosinusitis (CRS) is a multifactorial disease in a heterogenous group of diseases with different underlying etiologies and pathophysiologies, European and US studies have proposed its classification into four categories, i) acute bacterial rhinosinusitis, ii) CRS without nasal polyps, iii) CRS with nasal polyps (CRSwNP), and iv) allergic fungal rhinosinusitis. The histomorphological patterns of CRSwNP are characterized by Th2-driven immune responses including the predominance of eosinophils and mixed mononuclear cells with a relative paucity of neutrophils. Differing from European and US patients, Japanese patients with CRSwNP are thought to be subdivided into eosinophil-dominant, neutrophil-dominant, and eosinophil- and neutrophil-paucity types. The subclassified categories of CRSwNP were evaluated and supported by the clinical backgrounds such as disease severity, atopic status, recurrence, etc. Furthermore, the expression patterns of inflammatory parameters in each group were compared in order to clarify the immunological characteristics.
The treatment strategy for eosinophilic CRS is as follows. In selective patients showing extensive and massive sinonasal pathology a 7-day course of oral predonisolone tablets was administered before and/or after endoscopic sinus surgery (ESS). A short-term (3 to 5 days) of oral predonisolone was administered when olfaction judged by the self smell test was aggravated. Moreover, antibiotics were orally given in the presence of massive purulent nasal discharge. Bacterial infection may play a critical role in recurrent polyps and refractory symptoms during post-ESS follow-up. Moreover, worsening of sinusitis accompanies asthma exacerbation.
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カラー図説
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植田 広海, 内田 育恵, 岡本 啓希, 小川 徹也, 高橋 正克2013 年 106 巻 7 号 p. 582-583
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありPDF形式でダウンロード (1080K)
臨床
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神村 盛一郎, 遠藤 亜紀, 阿部 晃治, 北村 嘉章, 武田 憲昭2013 年 106 巻 7 号 p. 585-589
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありWe report herein on an intractable case of MPO-ANCA-associated middle ear disease with sensorineural hearing loss and facial palsy. A 73-year-old female complained of otitis media-like symptoms, but the treatment for otitis media with effusion was ineffective. She then showed bilateral progressive sensorineural hearing loss and facial palsy. PR3-ANCA was negative, but MPO-ANCA was positive in the serum. CT imaging revealed that the lesion was limited to the middle ear cavity without lesions in the lung and kidney. Non-specific findings were obtained in the histopathological examination of granular tissue of the mastoid cavity. She was diagnosed as having MPO-ANCA-associated middle ear disease with sensorineural hearing loss and facial palsy on the basis of the clinical findings and we administered cyclophosphamide in addition to a steroid. Discontinuance of the immunosuppressive therapy was, however, forced because of bacterial infection. Thereafter, steroid therapy alone failed to improve the left deafness, right moderate sensorineural hearing loss and right facial palsy.
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乾 洋史, 乾 健2013 年 106 巻 7 号 p. 591-597
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありThe postoperative results for the Yuasa method performed as a day surgery under local anesthesia between August 2000 and December 2012 were analyzed in 82 cases (75 cases of chronic otitis media, 4 cases of traumatic tympanic membrane perforation and others). The mean operating time was 37.4 minutes. The total rate of closure was 89.0%, and the total rate of successful hearing improvement was 91.5%. The perforations were classified into 4 groups. The rates of them were dropped in patients with large tympanic membrane perforation. In 4 patients with hearing aids who experienced the tympanic membrane perforations, the Yuasa method was performed to reduce the influence of conductive hearing loss. The patients’ subjective hearing levels all improved. Furthermore, for 32 cases who underwent the Yuasa method between January 2007 and December 2012, the patient satisfaction was examined using a questionary survey. During the postoperative stage, none of the patients experienced anxiety after their going home.
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―緊急手術の必要性について―朝日 淳仁, 久保田 圭一, 原渕 保明2013 年 106 巻 7 号 p. 599-604
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありWe encountered four cases of pediatric linear orbital floor fractures with entrapment of the muscle and/or fascial connective tissue. Preoperative CT scan showed the missing rectus sign in two cases, consistent with the intraoperative findings of inferior rectus entrapment. In the other two cases, CT showed an enlarged inferior rectus muscle. All of the patients presented with nausea, vomiting and ocular pain. The surgery had to be delayed in one of the patients with entrapment of the muscle, because of initial treatment at another hospital. This patient who underwent surgery 28 hours after the injury showed persistent upward gaze disturbance for 30 months after the surgery. All the other patients, in whom surgery was carried out as soon as possible, experienced complete recovery. Early operation as soon as possible is recommended for obtaining prompt relief of symptoms and avoidance of permanent sequelae such as upward gaze disturbance.
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井内 寛之, 永野 広海, 大堀 純一郎, 黒野 祐一2013 年 106 巻 7 号 p. 605-608
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありArteriovenous malformations (AVMs) of the deep lobe of the parotid gland are relatively rare. It is a structural vascular abnormality with no proliferation of cellular components.
A 63-year-old woman presented to the ENT service with a three-month history of swelling and pain on the left side of the parotid area. Enhanced CT revealed a high density spot and diagnostic angiography revealed a high-flow AVM in the deep lobe of the parotid gland. The operation was performed via the parotid gland approach, and the tumor could be removed by transecting the superficial temporal artery and the retromandibular vein but without any bleeding.
Histological analysis of the nodule revealed that the proliferating cellular area was composed of endothelial cells and pericytes in addition to the area of dilated vessels. As mentioned above, it was diagnosed an arteriovenous malformation. The AVM showed no evidence of recurrence on CT imaging at about six months after the operation.
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長谷川 博紀, 伊藤 真人, 吉崎 智一, 塚谷 才明2013 年 106 巻 7 号 p. 609-613
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありWe retrospectively examined the bacterial isolates, tolerance to antibiotics, and clinical course in 88 patients with peritonsillar abscess who were treated at the Matto Ishikawa Public Central Hospital between October 2007 and December 2012. Peritonsillar pus was collected by needle aspiration in 57 cases, and 90 strains of bacteria were detected and tested for drug sensitivity. In 16 cases (32%), only anaerobes were cultured. In 18 cases (35%), only aerobes were cultured. And in 16 cases (28%), both anaerobes and aerobes were cultured. In 3 cases (5%), neither anaerobes nor aerobes were detected. Overall, 6 of the 41 anaerobic strains (14.6%) and 8 of the 35 aerobic strains (22.9%) were resistant to clindamycin(CLDM). None of the 25 anaerobes were resistant to ampicillin/sulbactam (ABPC/SBT). The rate of resistance to ABPC/SBT among the aerobes was less than or equal to the rate of the resistance of aerobes to ABPC (9.8%). Against carbapenem (CBP), all 42 anaerobic strains did not have any tolerance, and only 2 of the 42 aerobes were resistant (4.8%). Judging from the above, ABPC/SBT might be suitable as a first-line antibiotic for the treatment of peritonsillar abscess, rather than CLDM, because of the low rate of drug resistance and the narrow spectrum. CBP should be regarded as a second-line treatment, since CBP abuse can induce tolerance.
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柴田 博史, 林 寿光, 久世 文也, 青木 光広, 水田 啓介, 伊藤 八次2013 年 106 巻 7 号 p. 615-619
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありPeritonsillar abscesses are the most common deep neck infection in adults. However, pediatric cases are very rare. Pediatric patients have a small anatomy which often impedes cooperation with examination and treatment. In this article, we examine four cases of pediatric peritonsillar abscess, and discussed its treatment, concentrating in particular on abscess tonsillectomy. We performed abscess tonsillectomy in one of our cases. This method allows complete drainage of the abscess, and can decrease the recurrence rate.
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今井 篤志, 鈴木 克佳, 森田 祥2013 年 106 巻 7 号 p. 621-625
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありA 30-year-old man fractured his thyroid cartilage while participating in Kendo, which is a Japanese sport that involves fighting with wooden swords. He complained of hoarseness and slight pain in the upper neck. Laryngoscopy revealed no vocal cord palsy but slight intralaryngeal hematoma and endolaryngeal swelling. 3-dimentional computed tomography (3D-CT) showed a fracture line in the left thyroid cartilage plate. Seven days after the injury, the inflammation and hematoma had reduced, however, the voice disorder remained. Decreased tension and shortness of the left vocal fold were also clearly revealed. Open reduction was performed with rigid internal fixation of the thyroid cartilage fracture using titanium miniplates under general anesthesia on the 16th day. The patient’s voice disorder fully recovered after 2 months.
External blunt injury to the larynx can cause not only acute airway trouble but also long-term voice or swallowing dysfunction. It is important to evaluate laryngeal injuries carefully and determine appropriate treatment in order to repair them appropriately.
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田中 泰彦, 佐藤 成樹, 富澤 秀雄, 中村 学, 深澤 雅彦, 肥塚 泉2013 年 106 巻 7 号 p. 627-630
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありEctopic hamartomatous thymomas (EHT) is an extremely rare disorder.
We report herein on a case of EHT occurring in the neck with a review of the literature. A 35 year-old man first noticed a swelling in his left cervical region at the beginning of March, 2005, and he came for a checkup in our department in March. In the initial examination, palpation revealed a 3×5 cm soft mass with a somewhat indistinct border in the left pars supraclavicularis plexus brachialis. There was no subjective symptom except swelling, and palpation revealed no anomaly in the cervical lymph nodes, and no other lesion was seen in the head and neck area.
A tumor was present within the sternocleidomastoid muscle outside the left lobe of the thyroid gland, and the MRI imaging did not show any involvement of the thyroid gland.
We performed a tumorectomy under general anesthesia. There was a tumor right under the sternocleidomastoid, there was no adhesions seen at the periphery of the tumor, and tumor removal went smoothly. The histological diagnosis was an ectopic hamartomatous thymoma.
In 1984, Rosai et al. proposed the concept of the EHT as a lesion having the character of both a hamartoma and a tumor also comprising cervical ectopic thymic tissue. No recurrence has been reported in cases where the tumor has been totally extirpated. In our present case, no recurrence has been seen in a 7-year postoperative follow-up.
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谷山 岳司, 杉山 智宣, 荒木 真美佳, 福喜多 晃平, 山田 弘之, 畠山 好央, 小山 真司, 細井 裕司2013 年 106 巻 7 号 p. 631-635
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありBetween 2000 and 2009, we surgically treated 25 patients with primary hyperparathyroidism and 15 patients with secondary hyperparathyroidism. We used a combination of ultrasonography, CT scans, and MRI for preoperative imaging. The preoperative diagnostic accuracy was 51% for ultrasonography, 46% for CT scans, and 76% for MRI. Postoperative complications occurred in 6 cases: 3 cases of temporary recurrent laryngeal nerve palsy, 1 case of permanent recurrent laryngeal nerve palsy, and 2 cases of postoperative bleeding. Parathyroid function increased again after surgery in 1 patient with primary hyperparathyroidism and 3 patients with secondary hyperparathyroidism. We could not remove all the morbid parathyroid tissue in these cases. Further efforts to increase the accuracy of preoperative diagnosis and study discrimination using pigments and an intraoperative intact PTH assay are needed.
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対馬 那由多, 黒田 徹2013 年 106 巻 7 号 p. 637-643
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありBetween July 2008 and November 2012, we treated 4 patients with cervical node metastasis from unknown primary sites (CUP) and 1 patient suspected as having CUP.
Every patient who was diagnosed as having CUP underwent random biopsy, bilateral tonsillectomy, neck dissection and radiotherapy. No primary lesion was detected by the random biopsy or tonsillectomy.
Two patients died of distant metastasis and the other 3 patients are surviving, including 1 patient in whom investigation is ongoing. In all five cases, the histopathological diagnosis of cervical lymph node was squamous cell carcinoma. Extracapsular spread was found in 3 cases. The 2 patients who died of distant metastasis had invasion of the blood vessels.
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鈴木 良, 土師 知行, 岡 愛子, 岩永 健, 大庭 晋, 坂本 進, 宮崎 拓也, 西村 一成, 千代田 朋子, 市丸 和之, 佐藤 進 ...2013 年 106 巻 7 号 p. 645-650
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありDeep neck infection is often seen in ENT practice and could become a life-threatening disease if it is not diagnosed promptly and is not treated properly. Airway management, proper antibiotics and management of purulent discharge are required. No criteria, however, exist for treatment of deep neck infection by surgery or by conservative management alone. The aim of this study was to review retrospectively cases of deep neck infection which were treated in Kurashiki Central Hospital and identify the characteristics of the surgical cases with bibliographic consideration. Descending necrotizing mediastinitis (DNM) is reviewed separately.
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松見 文晶, 大槻 好史, 佐藤 和則, 谷 亜希子, 多田 靖宏, 大森 孝一2013 年 106 巻 7 号 p. 651-657
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありLemierre’s syndrome is thrombophlebitis of the internal jugular vein due to head and neck infections, mainly oropharyngeal, and causes metastatic abscess such as in the lung. We report herein on a case of Lemierre’s syndrome following cervical cellulitis due to community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection. A 47-year-old woman with no particular past medical history presented to our hospital with a complaint of right neck swelling. She had a high grade fever, cough, and slight difficulty in breathing. Her submandibular area was swollen and red. Laboratory data showed an increase in white blood cells, C-reactive protein, D dimer and FDP. Contrast-enhanced computed tomography revealed cellulitis of the right submandibular area, right internal jugular vein thrombosis, and multiple lung nodules, which indicated septic emboli. MRSA was detected in her blood culture. She was diagnosed as having Lemierre’s syndrome, and intravenous linezolid and heparin were administered. Her thrombus and pulmonary lesions disappeared and she was discharged from hospital on the 41st hospital day.
Lemierre’s syndrome caused by MRSA is a very rare but treatable disorder. Not only should we consider Fusobacterium necrophorum, the most common organism of Lemierre’s syndrome, as the cause, but also other organisms including MRSA, regardless of it being a community–acquired infection. Empiric anti-MRSA therapy should be performed especially when Lemierre’s syndrome is suspected to be caused by dermal infection in the head and neck region.
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薬物
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山中 昇, 杉田 麟也, 宇野 芳史, 松原 茂規, 林 泰弘, 澤田 正一2013 年 106 巻 7 号 p. 659-667
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありChildren under the age of 2 years are in a functionally and immunologically immature state and are likely to have a refractory course when diagnosed with acute otitis media (AOM). To clarify the clinical characteristics of AOM in children under 2 years of age (AOM<2), the clinical backgrounds and bacterial pathogens were compared between AOM<2 and AOM in children aged 2 years or older (AOM≧2). Furthermore, the clinical efficacy of treatment with tosufloxacin (tosufloxacin tosilate hydrate, TFLX) on acute otitis media was evaluated in these two age groups.
The AOM<2 group had a higher incidence of recurrent and prolonged infections over 3 weeks compared with the AOM≧2 group. In the AOM<2 group, Haemophilus influenzae and Streptococcus pneumoniae, the 2 major pathogenic bacteria, were responsible for 66.7% and 25.6% of the cases, respectively, while in the AOM≧2 group, Haemophilus influenzae and Streptococcus pneumoniae were responsible for 41.1% and 70.5% of the cases, respectively. More than 90% of the isolates were antimicrobial-resistant strains, i.e., β-lactamase non-producing ampicillin resistant Haemophilus influenzae (BLNAR) or penicillin-resistant Streptococcus pneumoniae (PRSP).
The present study showed that TFLX was highly effective for the treatment of acute otitis media in both age groups.
Based on these results, AOM in patients who are under 2 years of age is likely to be more refractory and to be frequently caused by BLNAR and PRSP. We confirmed that TFLX is effective in patients with a recurrent and prolonged course and should be the drug of choice for children with pretreated and refractory AOM.
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研修ノート
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鴫原 俊太郎2013 年 106 巻 7 号 p. 668-669
発行日: 2013年
公開日: 2013/07/01
ジャーナル 認証ありPDF形式でダウンロード (254K)
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