Eosinophilic chronic rhinosinusitis (ECRS) symptoms include massive eosinophilic infiltration into nasal mucosa, nasal polyps, and curative resistance even postoperatively. How so many eosinophils migrate into nasal tissues is unclear, although infiltration is associated with intractability. Two factors considered potentially related are (1) increased eosinophils infiltration from blood vessels into tissue and (2) eosinophil “pools” in tissue due to age. During adherence in local eosinophil infiltration, vascular cell adhesion molecules (VCAM)-1 and alpha 4 beta 1 integrin (VLA-4) bind eosinophils selectivery. Tumor necrosis factor (TNF)-a or interleukin (IL)-4 stimulation increases VCAM-1 expression in vascular endothelial cells, multiplying nasal polyp fibroblasts. This, in turn, stimulates eosinophil infiltration. Eotaxin, a chemokine involved in eosinophil chemotaxis, is expressed significantly more highly in nasal polyp fibroblasts from those with ECRS in TNF-α and IL-4 costimulation than in those without ECRS. mRNA expression of IL-5, a cytokine important in eosinophil survival, is high in the nasal polyps of those with ECRS. The expression of tumor necrosis-factor-related apoptosis-inducing ligand (TRAIL), associated with eosinophil apoptosis, does not differ between those with and without ECRS, whereas that of TRAIL-R3 in peripheral blood eosinophils is higher in those with ECRS. High TRAIL-R3 expression suppresses eosinophil apoptosis. The above factors are, however, associated only partially with eosinophil infiltration, meaning that the mechanism must be further analyzed to clarify ECRS features and determine safe, effective treatment.
We recently studied the characteristics of vertigo and dizziness in 197 patients who first visited the emergency room (ER group) and in 288 patients who first visited the otorhinolaryngological clinic of Minoh City Hospital (ENT group) between January 1 and December 31 of 2009. The ER group can be regarded as representing the hyperacute phase and the ENT group as representing the acute to chronic phase. These two groups were completely distinct. We also subdivided these groups into the high risk subgroup (H subgroup) for cases with the underlying diseases of diabetes mellitus, hypertension, cerebrovascular disease and hyperlipidemia, and the normal subgroup (N subgroup). Comparison of the two groups showed that, in the ER group, a significantly larger numbers of patients had symptoms of peripheral vestibular origin except for BPPV and Meniere's disease, and a significantly larger number of patients had symptoms of unknown origin in the ENT group. Half of this group may be accounted for by patients with symptoms of peripheral vestibular origin except for BPPV and Meniere's disease in the ER group. In 8 out of 158 patients of the ER group and 1 out of 122 patients of the ENT group, cerebral lesions were not found on CT images but were found with MRI. Careful investigation is necessary in the patients with normal CT findings. Central vestibular lesions were found in 7 out of 197 patients (3.5%) of the ER group and 5 out of 288 patients (1.7%) of the ENT group. The incidence of central lesions tended to be higher in the ER group than in the ENT group. There was no significant difference in the incidence of central lesion among the H and N subgroups of both groups. Careful investigation of the central vestibular lesion is also necessary in the N subgroup.
Generally, the cause of facial palsy in children is more varied than in the case of adults. Birth trauma is one of them, but reports on this are few. It is possible that the palsy resolved spontaneously before the medical examination. We met with a case of birth trauma caused by forceps delivery. The female patient suffered severe facial nerve palsy and right ear bleeding after arrival. We report herein on the case and our clinical examination of facial nerve palsy in children at the local mainstay hospital. We reviewed 37 cases, ranging in age from 0 to 15 years, who demonstrated facial palsy at Niigata Prefectural Central Hospital between April 1998 and March 2008. The most common causes of facial palsy in children were Bell’s palsy (24 patients, 65%), followed by birth trauma (4 patients, 11%) and Hunt syndrome (3 patients, 8%). Of the 37 patients, 34 were followed up until their recovery or for longer than 6 months. One patient with a cerebellopontine angle tumor improved, another patient with congenital facial palsy remained unchanged, and the remaining 32 patients recovered completely. In 4 cases of birth trauma, the palsy resolved spontaneously within sixty days.
Malignant external otitis is an invasive infection of the external auditory canal mostly caused by Pseudomonous aeruginosa. The syndrome mainly affects elderly patients with diabetes mellitus. Though the patients were usually cured with conservative treatment using antibiotics, we present herein two cases of malignant external otitis in whom otological surgery was performed. Case 1 was a 35-year-old male with diabetes mellitus type 1. He was referred to our hospital after having been treated for several months with oral antibiotics for the left ear pain and discharge. On examination, the ear canal was severely edematous and erythematous. Cultures of aural drainage demonstrated P. aeruginosa and high-resolution computed tomography (HRCT) showed defects in the external auditory canal. Malignant external otitis was diagnosed, and the patient was treated with cefozopran. Because the patient suffered from ear discharge despite the treatment, surgery was eventually performed. His postoperative course was satisfactory and there is no sign of recurrence. Case 2 was a 63-year-old male with diabetes mellitus type 2. He was admitted after having been treated for 2 months with oral antibiotics for the swelling around the right temporomandibular joint and right ear pain and discharge. On examination, the ear canal was edematous and the retraction pocket on the Pars flaccida of the tympanic membrane was filled with keratinized debris. Cultures demonstrated P. aeruginosa. HRCT showed defects of the temporomandibular joint and the attic and tympanic cavity were filled with soft tissue. Malignant external otitis caused by cholesteatoma was diagnosed, and tympanoplasty with mastoidectomy was performed. The patient improved immediately and shows no sign of recurrence.
We report a case of bear-attack injury occurring in Tokyo. A 43-year-old jogger encountering an Asiatic black mother bear and a cub was bitten in the nose and right forearm. When seen at the hospital after transfer by a helicopter, he was alert and his vital signs stable. Aside from nasal fracture, soft tissue of the eyes, lacrimal duct, parotid gland, and facial nerve were intact. After liberal saline irrigation, we sutured his wound and administered antibiotics and tetanus prophylaxis. We also fixed his nose in place externally and internally to prevent nasal breathing obstruction. He was discharged on postoperative day 7 without severe complications. Because bear bites tends to be severe, and even fatal, they must be treated considering both functionally and cosmetically.
Tonsilloliths are calcifications that form in the crypts of the palatal tonsils. These calculi are composed of calcium salts either alone or in combination with other mineral salts, and are usually small, although there have been occasional reports of large tonsilloliths. We report herein on the case of a 37-year-old man who was experiencing pain and a foreign body sensation in his left throat. A large 25×15 mm tonsillolith was found in the crypt of the left palatal tonsil, 3.0 g in weight. The left palatal tonsil together with the tonsillolith was subsequently surgically removed. Although large tonsilloliths are rare, we suggest tonsillectomy as the surgical treatment of choice when tonsilloliths are combined with recurrent inflammation.
Acute epiglottitis can produce airway obstruction, so we must usually treat these patients immediately with airway control. In Japan, acute epiglottitis in adults is common, but acute epiglottitis in children is very rare. In this paper, 2 cases of acute epiglottitis in children are reported. One patient was a 3-year-old boy. He visited our hospital complaining of dyspnea, trouble with speaking and stridor. Fiberscope examination of the larynx revealed severe swollen epiglottis, so we diagnosed acute epiglottitis. We immediately performed a tracheotomy to maintain the airway. After 5 days, the swollen epiglottis had improved and the patient recovered completely within 10 days. We detected Haemophilus influenzae from the blood cultures. The other patient was a 2-year-old girl. She visited our hospital complaining of dyspnea and stridor. Fiberscope examination of the larynx revealed a moderately swollen epiglottis, so we diagnosed acute epiglottitis. We immediately performed tracheal intubation to maintain the airway. The next day, the swollen epiglottis had improved and she recovered completely within 10 days. We detected Haemophilus influenzae from the blood cultures. We describe the diagnosis and treatment of acute epigolottitis in children, especially with regard to airway control.
Congenital lateral cervical fistula is a branchial anomaly that is formed by the abnormal evolution of the branchial cleft. Most lateral cervical fistulas only have an external opening, so a complete lateral cervical fistula with an external and internal opening is rare. We report a case with a left complete lateral cervical fistula from the second cleft. A 9-year-old girl complained of mucal discharge from an opening in the left lower neck. A fistulography was performed to confirm the tract of the fistula, and the tract was found to end in the area of the mouth. We diagnosed the patient as having a complete fistula. The fistula was totally extirpated under general anesthesia. During the operation, two horizontal incisions were made in the neck, and an angiography guidewire was very useful as a guide. An internal opening was recognized in the middle of the posterior palatine arch. We concluded that the complete lateral cervical fistula was derived from the second branchial cleft.
We report a case of gas gangrene of the neck, a rare but life-threatening infection readily progressing to mediastinitis and damaging vital chest organs. A 80-year-old woman who had had a canine tooth extracted two days earlier developed left mandibular, neck, and chest gas gangrene. We conducted emergency surgical and antibiotic treatment with favorable results. Anaerobic Streptococcus milleri bacteria were identified in necrotic tissues. The woman has remained free of complications in the month since treatment underscoring the importance of early diagnosis, aggressive surgical drainage, and intravenous antibiotic administration in treating deep neck abscess.