The peripheral vestibular organs sense angular and linear accelerations of the head, and help to maintain gaze and posture during head movements through the vestibulo-ocular and vestibulo-spinal reflexes. Bilateral vestibular dysfunction causes persistent imbalance and oscillopsia while the body or the head is moved, and so far, no effective treatments have been found for this condition, except for vestibular rehabilitation. At present, various strategies are ongoing in being attempted around the world. Among these, I have outlined four strategies: 1) vestibular rehabilitation, 2) vestibular implantation, 3) noisy galvanic vestibular stimulation (GVS), and 4) regeneration of hair cells. 1) Vestibular rehabilitation is the only treatment that is available to treat bilateral vestibulopathy, although its efficacy remains controversial. 2) Vestibular implants, which stimulate each semicircular canal electrically, have been employed in the United States and Europe since 2000. Although several problems still remain to be resolved, clinical trials to examine the effects of vestibular implants have been conducted. 3) Our group has been developing noisy GVS, which is delivered as a zero-mean current noise of an imperceptible amplitude, to improve postural performance in patients with bilateral vestibulopathy. We showed that noisy GVS can improve postural performance in patients with bilateral vestibulopathy. We also examined the effects of noisy GVS on locomotion, and showed that it significantly increased the gait velocity and stride length in patients with vestibulopathy. Furthermore, we showed that long-term application of noisy GVS leads to improved postural stability that lasts for several hours after cessation of the stimulus. 4) Regeneration of hair cells from stems cells such as ES cells and iPS cells, has already been shown to be potentially successful, however, its clinical application remains a distant goal. Several clinical trials to promote regeneration of the hair cells using viral vectors are ongoing around the world.
Bullous myringitis is often accompanied by various types of hearing loss, including conductive, mixed, and sensorineural hearing loss. However, whether similar hearing loss develops in children, who account for the majority of cases of bullous myringitis, remains controversial.
Of 37 patients (aged 4–66 years) examined immediately after the onset of bullous myringitis, by both distortion product otoacoustic emission (DPOAE) and tympanometry, the tympanograms of 17 patients could not be categorized into any of the conventional types, i.e., type A to type C. The DPOAE responses were evaluated according to the number of significant responses at six frequencies. The means were 2.4 on the bullous side and 4.5 on the non-bullous side, indicating the poorer response on the bullous side. Pure-tone audiometry was performed in 27 patients, with 10 of these patients aged 12 years or younger. The mean hearing was 23.7 dB on the bullous side and 12.0 dB on the non-bullous side, showing worse hearing on the bullous side. According to the results, five patients had normal hearing, nine had conductive hearing loss, eight had mixed hearing loss, and five had sensorineural hearing loss. As for 10 patients aged 12 years or younger, seven patients had hearing loss; three had conductive hearing loss, two had mixed hearing loss, and two had sensorineural hearing loss. Either an atypical tympanogram or a reduced DPOAE response, or both, were observed in the patients with hearing loss. This study showed that DPOAE combined with tympanometry is a useful screening tool for patients with hearing loss.
In patients with bullous myringitis, hearing disorder is considered to be associated with Eustachian tube disorders, which also causes hearing loss in children. DPOAE combined with tympanometry test may be a useful tool for hearing evaluation in children who can not be successfully tested by pure-tone audiometry.
We report the case of a 6-year-old boy with atypical Ramsay Hunt syndrome and varicella-zoster virus (VZV) meningitis. The patient had a history of two chickenpox vaccinations. The patient experienced shingles in his left ear, headache and vomiting. VZV was detected by the analysis of cerebrospinal fluid using a polymerase chain reaction (PCR), and a diagnosis of VZV meningitis was made. Acyclovir and prednisolone were administered, and no sequelae occurred. Since October 2014, a periodic chickenpox vaccination program has been implemented in Japan, and this program is expected to decrease the incidence of chickenpox. Additionally, the prevention of herpes zoster or Ramsay Hunt syndrome, the etiology of which involves the reactivation of latent VZV in ganglion cells, is expected. Although no direct history of chickenpox has been observed after the implementation of the vaccination program, facial paralysis with herpes zoster oticus, as in this case, has been observed. Consequently, Ramsay Hunt syndrome should not be excluded from a differential diagnosis in patients with facial palsy even if they have a history of chickenpox vaccination. In patients with Ramsay Hunt syndrome and a history of vaccination, determining the causative virus, i.e., whether it is a wild strain or a vaccine strain, is important in discussion of etiology.
Pyogenic granuloma is classified as a benign vascular tumor, and sex hormones, infection and trauma are known to be involved in its pathogenesis. The treatment is surgical resection, but the highly vascular nature of the tumor may cause massive bleeding at the time of resection. Therefore, preoperative evaluation of the tumor vascularity and treatment planning for bleeding are required. In this article, we report a patient with pyogenic granuloma of the nasal cavity that was thought to be caused by nasal foreign bodies who required two operations. The patient was a 29-year-old male, who presented with left rhinorrhea and nasal congestion. Examination revealed a tumor lesion with a smooth surface protruding from the left anterior nostril. CT revealed soft tissue in the left nasal cavity and multiple nodular shadows with high density areas within it, suspected as foreign bodies. At the first operation, resection of the tumor caused massive bleeding. We determined that it was difficult to continue the operation and completed it after ensuring hemostasis. Subsequently, we performed contrast-enhanced CT to evaluate the lesion vascularity. The findings revealed persistence of the foreign bodies in the left nasal cavity, and a tumor showing contrast enhancement around them. The tumor was assessed as being highly vascular. In the second operation, arterial embolization was performed, which controlled intraoperative bleeding, prior to the endoscopic sinus surgery. Pyogenic granuloma can be caused by long-term persistence of foreign bodies. Because of the high vascularity of these lesions, a contrast-enhanced CT should be performed to evaluate the lesion vascularity prior to its resection. Arterial embolization performed at the appropriate time controls the bleeding during resection.
We developed a nasal symptoms questionnaire (NSQ), consisting of 10 items, to grasp the subjective symptoms of patients with chronic rhinosinusitis (CRS). In this study, we investigated the factors causing exacerbation of nasal symptoms in patients with CRS by examining the results of the NSQ, the patients’ background, and the clinical findings. The subjects were 287 patients who underwent endoscopic sinus surgery for CRS from June 2015 to December 2018. Based on the JESREC diagnostic criteria, 125 patients were classified into the eosinophilic chronic rhinosinusitis (ECRS) group (87 men and 38 women; mean age 50.7 years) and 162 patients were classified into the non-eosinophilic chronic rhinosinusitis (non-ECRS) group (89 men and 73 women; mean age 50.6 years). The relationships between the NSQ score and the 10 items that were considered as potential exacerbating clinical factors (age, sex, presence/absence of asthma, respiratory dysfunction, blood eosinophilia (%), results of active rhinomanometry, serum total IgE level, presence of perennial or seasonal allergic rhinitis, CT score according to the Lund-Mackay staging system, and the nasal polyp score) were analyzed by calculating the Spearman’s rank correlation coefficient. Furthermore, multiple regression analysis was performed using factors that were identified as being statistically significant (p<0.05) based on the Spearman’s rank correlation coefficient. In the ECRS group, presence of asthma, age, and blood eosinophilia were significantly correlated with the NSQ scores. In the non-ECRS group, age, blood eosinophilia, results of active rhinomanometry, and the CT score were significantly correlated with the NSQ scores. The results of multiple regression analysis showed that presence of asthma and age were significant factors in the ECRS group, while age alone was identified as a significant factor in the non-ECRS group. Based on the results of this study, we concluded that symptoms associated with rhinosinusitis become milder as the patients get older.
It is said that Horner syndrome and first bite syndrome (FBS) could occur after cutting off the sympathetic trunk during surgery for parapharyngeal space tumors. We encountered a patient who developed FBS without Horner syndrome after removal of a parapharyngeal space tumor, which was eventually diagnosed as a sympathetic schwannoma.
A 59-year-old male patient was detected by ultrasonography as having a tumor near the external carotid artery. MRI showed a moniliform-shaped parapharyngeal space tumor surrounding the external carotid artery, and fine-needle aspiration cytology revealed some cells with spindle-shaped nuclei. There was no evidence of any neurological deficit. We performed resection of the the parapharyngeal tumor, which was not apparently connected to any nerve. The external carotid artery was ligated, because it was surrounded by the tumor. Seven days after surgery, he developed preauricular pain at the beginning of a meal and was assumed to have developed FBS. The curtain sign was also positive, but there was no evidence of Horner syndrome. Histopathological examination of the tumor revealed the diagnosis of schwannoma.
It is reported that FBS occurs when sympathetic innervation from the superior cervical ganglion to the parotid gland is lost and the receptor sensitivity on the parotid gland increases. Since the sympathetic nerve branch to the parotid gland runs around the external carotid artery, it is reported that FBS more commonly appears in cases where the external carotid artery is sacrificed. In our case, the tumor surrounding the external carotid artery and the fact that the patient developed FBS without Horner syndrome after surgery suggest that the tumor arose from the sympathetic branch to the parotid gland. The case also lends support to the hypothesis proposed to explain the mechanism of development of FBS.
The principal causes of obstructive sleep apnea (OSA) in children are upper airway obstruction caused by the palatine tonsils and adenoid hypertrophy; consequently, tonsillectomy and adenoidectomy are the standard treatments for childhood OSA. However, most patients suffer from pain after a tonsillectomy, and many children cannot consume sufficient calories after surgery. Conventionally, diets based on porridge and chopped side dishes have been offered to children after a tonsillectomy in our hospital. On the other hand, when a child has gastroenteritis or dehydration, parents typically provide an oral rehydration solution or pouch jelly, but few parents currently give rice porridge to children. Although children who are suffering from pain after a tonsillectomy are unlikely to eat rice porridge if they are seeing it for the first time, the diet provided by the hospital has not changed. Here, we improved the diets provided to children after a tonsillectomy. The new diets are characterized by (1) the prohibition of rice porridge, (2) the prohibition of chopped side dishes, and (3) the provision of child-friendly supplements, such as yogurt and ice cream.
We compared the new improved diet with the conventional diet in terms of food intake, calorie intake, additional need for an intravenous drip, and period of hospitalization. With the new diet, marked improvements in food intake, calorie intake, need for an intravenous drip, and period of hospitalization were seen.
Polymorphous low-grade adenocarcinoma (PLGA) is a rare tumor that typically occurs in minor oral salivary glands. Our review of the literature found only three reported cases of PLGA of the nasopharynx. We herein report a case of PLGA of the nasopharynx.
An 81-year-old woman was referred to our hospital with symptoms of right nasal obstruction, epistaxis and a feeling of fullness in the right ear for one month. A nasal endoscopy examination revealed a tumor in the right nasopharynx. A magnetic resonance imaging (MRI) examination revealed a 26-mm well-enhanced mass over the right posterior nasopharynx. Endoscopic removal of the tumor was undertaken via an endonasal approach. A histological examination of the surgical specimen showed that relatively uniform cells with round nuclei and slightly acidophilic cytoplasm had infiltrated and proliferated in a tubular, papillary, and alveolar manner. Immunohistochemically, the tumor cells were positive for S-100 protein, vimentin, and bcl-2. The final diagnosis was PLGA. We did not perform any postoperative therapy because the area containing the malignancy was far from the surgical margin. Two years after the surgery, the patient is continuing to receive follow-up care and has not shown any signs of tumor recurrence. PLGA can recur even after long periods of time, and strict follow-up care is necessary.
We report the treatment policy for super-elderly patients with head and neck carcinoma. Data of 12 patients over 90 years of age with head and neck carcinoma who recently visited our department from January 1, 2014, to December 31, 2018, were analyzed. The medical records were retrospectively examined for each patient and the performance status score (PS) at the first visit, treatment, and the course after treatment were determined.
Six patients underwent radical treatment with surgery, two patients underwent palliative treatment, and four patients received no treatment. The PS tended to be good in the radical treatment group, but poor in the palliative treatment and untreated groups.
Patients with a good PS tended to choose radical treatment. The patients in the radical treatment group tended to survive longer than those in the remaining two groups. There were no treatment-related deaths in the radical treatment group, and there were some cases with a good life prognosis. Based on the above results, we believe that it is not necessary to avoid radical treatment in the super-elderly because of their advanced age. In addition, PS is one of the variables that may need to be considered when selecting surgery as radical treatment. In the radical treatment group, it is assumed that the PS would decrease in all cases as an inevitable price of treatment. When selecting curative treatment for a super-elderly patient, it is necessary to carefully examine each case to determine whether he/she can sufficiently tolerate the invasiveness of the intended treatment and the expected decrease of the PS associated with the treatment.
We retrospectively reviewed the data of super-elderly patients with carcinoma of the head and neck and concluded that there is little need to avoid radical surgical treatment in these patients because of the advanced age, although candidates for invasive treatment should be selected carefully. Preoperative PS is a useful index for the selection of invasive treatment options.