The stapedius muscle constitutes one of the efferent feedback pathways to the auditory periphery, which can be elicited by sound in either ear. Contraction of the stapedius muscle causes attenuation of the low frequency component of the input signal by increasing the stiffness of the ossicular chain. The effects of the acoustic reflex have been investigated for many years and a number of hypotheses have been proposed. Two of these hypotheses are: (1) that this reflex helps to protect the ear from acoustic injuries and (2) that it aids in the control of masking. However, there is still significant controversy as to its functional significance. In the present paper, possible functional roles of the stapedius muscle are discussed based on the physiological properties of the acoustic reflex of this muscle.
We report a case of P-ANCA positive Wegener’s granulomatosis (WG) with progressive hearing loss. A 63-year-old woman consulted a hospital complaining of right hearing loss. While she received therapy under diagnosis of sudden deafness, she developed a right facial nerve palsy and branch retinal artery occlusion. She was diagnosed as having WG based on specific symptoms in the upper respiratory tract (otitis and sinusitis), pathological findings in the nasal mucosa and blood test data including positive findings for P-ANCA. After she achieved remission induction with corticosteroid and immunosuppressant administration, hearing improved markedly and P-ANCA turned negative. Six years after remission, she demonstrated combined hearing loss in her left ear. Five years later, hearing loss in the left ear progressed acutely. Hearing loss was partially improved by medication at each episode, but has generally progressed during the past eleven years. The long-term clinical course showed that the titer of P-ANCA increased several months prior to the exacerbation of the hearing loss and coincidentally became negative with hearing improvement. This case provides a clinical example showing that P-ANCA can be used as an early marker for disease progression in P-ANCA-positive WG.
A case of paraneoplastic opsoclonus-myoclonus syndrome with an onset of vertigo is reported. A 72-year-old man complaining of vertigo, nausea and vomiting consulted our hospital on March 13, 2006. Since neurological examination showed opsoclonus of the eye movement, ataxia and adiadochokinesis, disequilibrium due to a central nervous system disorder was strongly suggested. Brain MRI did not demonstrate any evidence of tumor or ischemic lesion. CSF analysis did not show any malignant cells. However, lung X-ray image showed an abnormal shadow in the upper lung field. Therefore, a biopsy was performed under bronchoscopy and small cell lung carcinoma was diagnosed. Based on these findings, the patient was diagnosised as having paraneoplastic opsoclonus-myoclonus syndrome from small cell lung carcinoma. Anti-Ri and anti-Hu antibodies were unremarkable. He was treated with antidinic, psychomimetic and antineoplastic therapies. Vertiginous sensation and nausea decreased but opsoclonus persisted. He died of pneumonia on June 30th, 2006.
This clinical trial investigated whether a new rehabilitation therapy using the sensory substitution system was an effective treatment for severe balance disorder in subjects with bilateral vestibular loss. The device which substitutes for vestibular input by transmitting information on head position to the tongue, consists of a tilt sensor for detecting head position, a 10×10 electrode array for interfacing with tongue, and a controller for processing information. Subjects who placed the electrode array on the tongue were trained to maintain a centered body position by keeping the signals on the middle of tongue using the electrode array. All subjects completed 5-20 minute training sessions 2-3 times per day for 8 weeks. Dynamic stability and gait function were tested using the Sensory Organization Test (SOT) and Dynamic Gait Index (DGI), respectively, before and after all training sessions. All subjects showed pronounced improvements in their balance performance. The average of SOT score and DGI had significantly decreased after the last training. Improvements were also noted in quality of life assessments such as the Dizziness Handicap Inventory (DHI) and the Activities-specific Balance Confidence (ABC) Scale. These results suggest that alternative sensory input through the tongue could substitute for vestibular function and the vestibular substitution device is a possible new rehabilitation tool for subjects with a persistent balance disorder who have a long term history of bilateral peripheral vestibular etiologies.
We experienced a case of Ramsay Hunt syndrome accompanied by acute cerebellar ataxia. The patient was a 70-year-old woman who developed left facial palsy with otalgia, typical findings of Ramsay Hunt syndrome. She was treated with an antiviral reagent and steroid under admission; however, she noticed dizziness about 1 week later. Flutter-like oscillations and gaze nystagmus were noted. These neurological signs and symptoms were found to have been caused by varicella-zoster virus infection via an auto-immune mechanism.
Magnetic resonance imaging (MRI) has played a central role in the diagnosis and management of multiple sclerosis (MS), a prototypic inflammatory demyelinating disorder of the central nervous system. We compared the results of neuro-otologic examination with those of MRI in 9 patients with MS admitted to the Neurology Ward of Shimane University Hospital. Five patients were male and four were female. Patient ages at onset ranged from 13 to 57 years old, (mean, 38.6 years). Patients had sufferd from MS for 2 to 31 years (mean, 11 years). Primary symptoms were numbness, diplopia, anarthria, or weakness. All patients had brain and spinal cord lesions on MRI. Five patients showed abnormal findings on neuro-otologic examination. Medial longitudinal fasciculus (MLF) syndrome is one of the most frequent disorders of the brainstem in MS, and was present in 3 patients. Of these 3, we present 2 patients in whom the findings of neuro-otologic examination were compared with MRI findings at the time of review. In patient 1, a 37-year-old man, MRI findings correlated with those of the neuro-otologic examination, amelioration was verified in the results of both examinations upon improvement of the pathology. In patient 2, a 35-year-old man, MRI showed a lesion in the medulla spinalis, but did not indicate a lesion in the brainstem. However, this patient had MLF syndrome on neuro-otologic examination, which was consistent with the symptoms. In this instance, neuro-otologic examination, which was consistent with the symptoms appeared to be more sensitive than MRI. MRI is an invaluable diagnostic tool but it cannot identify all lesions in MS. We emphasize that, in addition to MRI, neuro-otologic examination is useful in the diagnosis or evaluation of MS.
Six surgically treated patients with orbital complications caused by acute sinusitis were analyzed. Three presented with orbital abscess, and three presented with orbital subperiosteal abscess. In all cases, the removal of the orbital plate was performed, and, in addition, patients with orbital abscess underwent incision of the periorbita. After surgery, all patients fully recovered from visual disturbances, except for one whose surgery was delayed for 28 days after the orbital symptoms had appeared. Since both the removal of the orbital plate and incision of the periorbita do not involve postoperative complications, these procedures should be performed at an early stage if necessary for the improvement of the visual function.
We performed endoscopic re-operation on a patient with a relapsed cyst of the right sphenoidal sinus under X-ray imaging. The case was a 59-year-old man complaining of double vision due to a right sphenoidal cyst, and cysts of the bilateral sphenoidal sinus had been operated on at 52 years old. Because of postoperative stenosis of the right nasal cavity, we endoscopically opened the right sphenoidal cyst through the left sphenoidal sinus. In order to avoid skull base injury, endoscopic opening of the cyst wall was performed securely under X-ray imaging. X-ray imaging is a useful tool supporting endoscopic sinus surgery, as an alternative to the navigation system.
Isolated sphenoid sinusitis is rare and difficult to diagnose. The difficulty arises because it is located in the deepest part of the nasal sinuses and the associated inflammation does not lead to typical symptoms of sinusitis. There are many important structures in the vicinity of the sphenoid sinus: the internal carotid artery, cavernous sinus and cranial nerves. Therefore, sphenoid sinusitis causes severe complications. From January 2003 to December 2007, we encountered 15 patients with isolated sphenoid sinusitis. Its incidence in all sinus diseases is 2.2%. Many patients complain of headaches, and they often visit neurologists or neurosurgeons. The pathological spectrum included 10 cases of bacterial sinusitis (5 acute sinusitis, 3 chronic sinusitis and 2 asymptomatic sinusitis), 3 fungal sinusitis, 1 mucocele and 1 retention cyst. When we diagnose isolated sphenoid sinusitis, CT and endoscopy are essential. CT becomes a more useful tool for performing a differential diagnosis when we independently change the window height and width. The endoscopic findings regarding draining from the sphenoethmoidal recess may indicate the severity of inflammation. A detailed observation with CT and endoscopy is the most important to accurately diagnose the pathology of isolated sphenoid sinusitis.
The patient was a 64-year-old man with an infra-auricular mass. Since the tumor was strongly adherent to the angle and the posterior aspect of the mandible, part of the medial pterygoid muscle, masseter muscle, and parotid gland, it was bluntly dissected and resected en bloc. The resected tumor was measured 65×50×13 mm, and weighed 31 g. The tumor was histopathologically diagnosed as an intramuscular lipoma, presumably arising from the sternocleidomastoid or masseter muscle. The reported recurrence rate of non-infiltrating lipoma is less than 5%, whereas that of infiltrating lipoma ranges from 3 to 62.5%. Since intramuscular lipoma is characterized by an infiltrating growth pattern, it cannot always be completely resected. To reduce its recurrence, it is necessary to perform a wide en-bloc resection of the adjacent normal muscle, while considering the degree of residual muscle dysfunction, including muscle weakness.
We analyzed the clinical courses, pathological findings, and methods of surgery in 5 patients with recurrent pleomorphic adenomas of the parotid gland. Of the 5 patients, 3 were male and 2 were female. The average age was 38.8 years at the first surgery. The mean interval to recurrence was 7.6 years, ranging from 2 to 17 years. Total or partial parotidectomy was performed in all 5 patients. Second recurrence after surgery was not recognized in four out of the five over an average period of 36.6 monthes. However, one patient experienced recurrence four times, and metastasis to the neck lymph nodes was suspected on MRI. Most recurrences of the parotid tumor show a myxoid type, but this trend was not recognized in the present study. It is essential that the complete resection of the tumor and surrounding tissue, including scar tissue of the skin, mastoid tip, and muscles, be carried out during surgery. Although preservation of the facial nerves is important, it is sometimes necessary to sever them. A few of these tumors may become malignant, and so recurrent tumors should be followed up carefully.
Tonsillectomy is one of the most common surgical procedures performed by otolaryngologists. Various devices have been introduced in recent years to achieve hemostasis with minimal tissue injury. The Harmonic Scalpel® is a useful surgical instrument for hemostasis, causing less injury to surrounding tissues than other instruments. The advantages of the Harmonic Scalpel® in tonsillectomy were evaluated in this study. We reviewed 308 patients who all underwent tonsillectomy using the Harmonic Scalpel® in our department from 2002 to 2008. The mean operation time for tonsillectomy was 24.6 min. The number of postoperative hemorrhage cases was 19 (6.3%). In most cases, the volume of intraoperative blood loss was too small to measure. We conclude that the Harmonic Scalpel® should be used widely in tonsillectomy. It is useful in reducing both the operative time and procedure-related blood loss, and is easily mastered.
The first case was a 73-year-old man complaing of neck swelling, hoarseness, and bloody sputum following a forceful blow to the anterior neck region by a pipe. Layngoscopy showed that the arytenoid was swollen and reddish; therefore, his vocal cords could not be observed. Computed tomograpy showed severe pneumoderma around the hyoid bone. Tracheotomy was urgently performed to open the air way and prevent pneumoderma. He was also hospitalized and treated with antibiotics. Thereafter, findings on laryngoscopy improved 23 days later. The second case was a 71-year-old man who accidentally hit the right side of the anterior neck against the corner of a chair. He complained of hoarseness and swallowing pain during a consultation with a local physician the next day. Laryngoscopy showed that the right vocal cord had developed a hematoma. As the air way was sufficiently conserved, thus he was observed without medication or hospitalization. Thereafter, his complaints subsided and findings on laryngoscopy improved 23 days later.
Head and neck cancer is frequently accompanied with other primary cancers, especially esophageal cancer. Among 337 cases with head and neck cancers treated at Mie University Hospital from January 2001 to December 2005, 31 cases (9.2%) had multiple cancers. Oropharyngeal cancer and hypopharyngeal cancer cases showed esophageal cancer significantly more frequently than other head and neck cancer cases (25.0-26.7%). Brinkman's index was significantly higher in the group with cancer of the oropharynx associated with esophageal cancer than in the group without any other primary cancer. Sake index was significantly higher in the group with cancer of the oropharynx or hypopharinx associated with esophageal cancer than in the group without any other primary cancer. Endoscopic examinations should be routinely performed after the treatment of head and neck cancer.