A 10-year-old boy having right-ear hearing impairment since elementary school had no history of aural infection and a normal tympanic membrane. Right middle-ear anomaly was diagnosed based upon audiometric findings of 30 dB conductive hearing loss and underdevelopment of the right long incus process found in computed tomography (CT). The long process of the incus and the stapes superstructure was absent and loose fibrous change in both ossicles was found. A small ‘open’ cholesteatoma matrix occupied the area from the promontory to the lower facial canal. The lack of direct contact of the cholesteatoma matrix with ossicles and no sign of inflammation confirmed the congenital nature of this anomaly. This case points out the difficulty of diagnosing small congenital cholesteatoma despite fine CT and the need for a careful observation of the tympanic cavity during surgery.
In response to the many complaints by the hearing-impaired about poorly fitted hearing aid obtained at hearing-aid shops and to dispense the most appropriate hearing aids, we opened a consultation clinic at the Akita Medical Center in 1986. In 1999, we introduced a microbus to make the rounds of ear, nose, and throat ENT, clinics in the prefecture. From 1986 to 2008, we saw 12,156 subjects and dispensed new hearing aids to about 70%. Hearing-aid fitting and dispensing by ENT doctors, auditory paramedical staff, and hearing-aid shops thus proved very useful to the hearing-impaired requiring hearing-aid assistance.
We report the case of a 22-year-old man with delayed cerebrospinal fluid (CSF) rhinorrhea onset attributed to a head injury. He developed CSF rhinorrhea and meningitis 15 years after injuring his head in a traffic accident. Coronal computed tomography (CT) and magnetic resonance imaging (MRI) proved useful in determining the leakage site precisely. We confirmed a fistula of the right cribriform plate in transnasal surgery, sealing it with fascia and fibrin glue. The man has had no CSF rhinorrhea or meningitis recurrence in the 18 months of follow-up.
Nasal obstruction may cause sleep apnea and changes in breathing routes, but it remains unclear how breathing route changes affect obstructive sleep apnea syndrome (OSAS). We evaluated the relationship between breathing route and OSAS severity. We conducted polysomnography on 45 subjects with OSAS but no nasal obstruction in awake state using simultaneous multipoint pressure measurement. Pressure sensors were placed in the pharyngeal cavity such at the epipharynx, the oropharynx immediately below the soft palate, the hypopharynx next to the posterior tongue, and in the esophagus. Subjects were divided based on negative pressure epipharynx into 3 groups—nasal breathing with nasal obstruction (n=13), normal nasal breathing (n=16), and oral breathing (n=16). The apnea hypopnea index (AHI) of the oral breathing group was 52.0/h—significantly higher than in the nasal obstruction group at 32.1/h and the normal nasal breathing group at 24.4/h. The pressure study indicated that oral breathing obstructs the upper airway in the oral cavum and at tongue base, and that nasal obstruction in turn generates negative pressure in the epipharynx collapsing the lower upper airway. In contrast, nasal breathing normally obstructs the upper airway only via the uvula in OSAS during sleep. Severity thus clearly differs between oral and nasal breathing during sleep. Subjects with OSAS breathing orally during sleep tend to have a higher AHI than subjects with nasal breathing due to severe hypopharynx airway obstruction.
We report a case of actinomycosis of the nasal cavity. A 45-year-old woman seen for bloody nasal discharge but no oral trauma or tooth extraction history was found in plain computed tomography (CT) to have a left nasal cavity mass destroying the uncinate process and ethmoid cells. Histopathological examination of the specimen following endoscopic nasal surgery yielded a diagnosis of actinomycosis. Nasal cavity or paranasal sinus actinomycosis is very rare, with only 11 isolated cases reported in Japan. Clinically, nasal or paranasal actinomycosis in the 12 cases we analyzed were (1) all unilateral, (2) showed bony wall destruction on CT in 6 cases (54.5%) and focal calcification in 8 (72.7%), and (3) required surgical treatment and experienced no recurrence.
We retrospectively analyzed postoperative adenoid tissue proliferation after adenotomy in 41 cases of pediatric sleep-related breathing disorder. Subjects were 35 boys and 6 girls with an average age of 4 years and 8 months. Adenoid size was evaluated by lateral X-ray pre-and postoperatively every 6 months. Complete surgical adenoid resection was done in 27 cases (66%) and incomplete resection in 14 (34%), although residual adenoid size was very small and did not disturb nasal breathing postoperatively. Of the 41 cases, 11 (27%) showed postoperative adenoid tissue growth. 11 cases emerged after 6 months postoperatively. None showed reproliferation more than 18 months postoperatively. We found reproliferation in 6 of 27 complete excisions. At 3 years old. 5 of 6 cases showed the reproliferation despite successful adenoid resection. Healthcare professionals should thus monitor the postoperative adenoid proliferation in younger children.
We studied clinical services for sleep-related disorders in breathing (SDB) by questionnaires sent to 150 hospitals and clinics in Shiga Prefecture identified through sleep clinic and Shiga hospital referrals. Responses returned by 82 (54.7%) showed that SDB cases 6,448 numbered a year, with 936 new and follow-up 5,370. Of these, 94.3% visited medical institutions in the cities of Otsu or Kusatsu. Shiga Prefecture has 9 beds for polysomnography (PSG) at 10 facilities. PSG conducted annually numbered 753 with most done in hospitals. PSG and portable sleep monitoring were not done in 3 areas. We estimated the annual number of PSGs in Shiga Prefecture in 2008 to be 53.8/100,000. All sleep technicians are employed part-time, severely limiting number of split-night, multiple sleep latency, and maintenance wakefulness tests. In conclusion, SDB treatment in Shiga Prefecture is concentrated at 2 hospitals in Otsu and Kusatsu, and annual PSGs per 100,000 are insufficient. SDB treatment and networks must therefore be built up among home doctors and medical institutions if SDB practice is to improve.
We compared pulse oxymeters and SleepStrips in sleep apnea syndrome (SAS) screening. We conducted pulse oxymeter (Pulsox-M24 and Me300, Teijin Inc., Tokyo, Japan) and SleepStrip (SLP Ltd., Tel Aviv, Israel) simultaneously at the homes of 85 subjects with suspected sleep apnea syndrome recruited from August 2006 to August 2007. Polysomnography (PSG) was later conducted with Alice4 (Respironics Inc., Murrysville, PA, USA) at the hospital. The 3% oxygen desaturation index (ODI3) with pulse oxymeter and the SleepStrip score based on the respiratory disturbance index (RDI) were calculated by automatic analysis. The apnea hypopnea index (AHI) in PSG was calculated by manual scoring. The correlation coefficient of ODI3 and RDI to PSG AHI was 0.802 (p<0.0001) and 0.557 (p<0.0001). A difference was seen in the Bland-Altman plot between ODI3 and AHI, and the ratio of ODI3 to AHI was underestimated. The area under the curve (AUC) of the SleepStrip was <0.8 and that of the pulse oxymeter was ≥0.9, at each cutoff. Agreement rate, over-diagnosis and under-diagnosis of these to PSG were 45.9% vs 70.6%, 34.1% vs 25.9%, and 20.0% vs 3.5%. Although the best cutoff from receiver operating characteristic curves (ROC) of SleepStrip are RDI≥25, AUC<0.8, the positive and negative likelihood ratios (LR+, LR-) were 3.2 and 0.4. These results indicate that SleepStrips are not effective in SAS screening. The best pulse oxymeter cutoff was 7.2, sensitivity was 0.914, and specificity was 0.815. Positive LR was 4.93 and negative LR 0.106, so pulse oxymetry can be used effectively to rule out SAS. Although pulse oxymetry was more effective in screening than SleepStrip, its use involved a difference and underestimation between ODI3 and AHI. We concluded that both devices were inadequate in home screening for SAS.
A 73-year-old woman reporting left-eye pain, left proptosis, left abducens palsy with diplopia, headache and nausea while being treated for chronic sinusitis was found to have signs of sphenoiditis and ethmoiditis in computed tomography (CT) and magnetic resonance imaging (MRI). We conducted endoscopic sinus surgery on suspicion of orbital apex syndrome due to chronic sinusitis, finding the left sphenoid sinus to be filled with yellowish-white caseous tissue underlaid with abnormal pathologycal mucosa. Pathological examination of abnormal tissue yielded a diagnosis of diffuse large B-cell lymphoma. The lesion was considered the primary one after systemic imaging showed no other lesion. Complete remission was obtained after 6 courses of rituximab THP-COP. A primary malignant lymphoma sphenoid sinus lesion is very rare.
We evaluated upper airway patency in conservative treatment of sleep-related obstructive breathing disorders. Subjects numbered 51−44 men and 7 women with a mean age of 55.3±10.2 years, a mean body mass index (BMI) of 26.9±3.2 kg/m2—with obstructive sleep apnea or snoring. All underwent daytime polysomnography with simultaneous upper airway and intraesophageal pressure monitoring. Nine lost weight, going from a baseline BMI of 30.1±2.9 kg/m2 to 26.8±3.4 kg/m2 after one year. Weight loss significantly reduced the apnea+hypopnea index from 80.7±30.3/h to 43.9±35.9/h and improved mesopharyngeal and intraesophageal pressure. Good response—defined as at least 50% reduction in the initial apnea+hypopnea index—was 50% (4/8) in patients using TheraSnore, and 58.8% (10/17) in patients using custom-made prosthetic mandibular advancement. Good responders were 40% (6/15) in patients with SNOR-X, and 57.1% (4/7) in patients with a custom-made tongue-retention device. Mesopharyngeal, hypopharyngeal, and intraesophageal pressure significantly improved with oral appliances. Pressure differences between the epipharynx and mesopharynx and between the mesopharynx and hypoparynx also significantly improved with oral appliances. We concluded that upper airway patency after conservative treatment is confirmed by simultaneous upper airway and intraesophageal pressure monitoring during polysomonography.
We compared respiratory events analyzed using a nasal-oral cannula/pressure sensor or thermocouple airflow sensor. Subjects numbered 29—24 men and 5 women with a mean age of 55.8±12.0 years—reporting snoring or obstructive sleep apnea and underwent all-night polysomnography. Respiratory airflow was simultaneously monitored using a nasal-oral thermocouple airflow sensor and a nasal-oral cannula connected to a pressure transducer. Respiratory events were manually analyzed from the thermal sensor, pressure sensor, and both sensors signals. The mean apnea-hypopnea index and apnea index analyzed using the pressure sensor exceeded the means analyzed using a thermal sensor at 33.6±22.8/h vs 30.5±22.8/h, 29.4±21.0/h vs 23.2±21.8/h. The mean hypopnea index analyzed using the thermal sensor was greater than the mean analyzed using the pressure sensor (7.3±10.9/h vs 4.2±7.4/h). The pressure sensor was more sensitive than the thermal sensor in detecting respiratory events, whereas the pressure sensor may have overestimated the number of apnea cases compared to the thermal sensor. The thermal sensor may overestimate the number of hypopneas compared to the pressure sensor. We therefore propose simultaneous monitoring with a nasal-oral pressure sensor and thermal sensor, which significantly improves respiratory event detection.
Allergen immunotherapy is a global effort in the managing allergic rhinitis. Using questionnaires, we clarified long-term prognosis in children with allergic rhinitis due to house dust. Nasal symptoms improved in 42.1% treated with medicine, compared to 73.5% in those undergoing immunotherapy. Immunotherapy also appears to retard progression from rhinitis to asthma.
To clarify laryngeal cancer practices, we followed up 95 cases—92 men and 3 women with a mean age of 66.3 years between 1990 and 2003. Supraglottic cancer was found in 26.3% (25 cases), glottic cancer in 71.6% (68), and subglottic cancer in 2.1% (2). Based on International Union Against Cancer “tumor/node/metastasis” (UICC TNM) classification, a difference exists in glottic and supraglottic distribution. Of glottic cases, 39 (57.4%) were stage I, 8 (11.8%) stage II, 10 (14.7%) stage III, and 11 (16.2%) stage IV. Of supraglottic cases, 2 (8%) were stage I, 2 (8%) stage II, 4 (16%) stage III, and 17 (68%) stage IV. Cervical lymph node metastasis was detected in 8.8% of glottic cases and 76.0% of supraglottic cases. Overall 5-year cumulative crude survival was 74.5% and cause-specific survival 85.7%. For glottis cases, 5-year cumulative crude survival was 83.6% and cause-specific survival 92.5%. For supraglottic cases, they were 56.0% and 73.5%. For stages I-IV, 5-year cause-specific survival was 100%, 87.5%, 78.6%, and 80.0% for glottic cases and 50.0%, 50.0%, 75.0%, and 79.3% for supraglottic cases.
We report a case of myoepithelial soft-palate carcinoma, a rare salivary gland tumor. A 72-year-old woman seen for oral-cavity discomfort, was found in magnetic resonance imaging (MRI) to have a well-defined solid mass in the submucosal soft palate. She had had a tumor at the same site surgically removed about 30 years earlier. The tumor was totally resected and histopathologically diagnosed as myoepithelial carcinoma arising from pleomorphic adenoma. The woman is currently disease-free for four years and two months postoperatively.
Lipoma, a benign tumor consisting of mature fat cells, occurs frequently in subcutaneous tissue but rarely in the pharyngeal submucosa. We report a case of epipharyngeal lipoma in a 54-year-old man seen for severe rhinolalia and snoring. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a well-defined solid mass occupying the pharyngeal space, whose histological biopsy disclosed to be lipoma. The tumor was surgically removed in an oral approach, relieving obstructive symptoms. The man remains symptom-free for one year and five months after the surgery.
We report an extremely rare case of face and neck tumoral calcinosis. A 56-year-old woman seen for a hard tumor in her cheek was found to have inflammatory change in the right buccal region. Computed tomography (CT) showed several calcification masses in soft cheek and neck tissue. The calcified cheek lesion was resected and histologically confirmed to be a tumoral carcinosis.
PURPOSE: Sentinel lymph node (SLN) biopsy is a standard surgical procedure in those with early-stage tongue cancer. Radioisotopes (RI) and a gamma probe are generally used to detect SLN, but RI can only be done at specialized institutions. SLN mapping with radiotracers is difficult if the SLN is close to the injection site because of shine-through radioactivity. We studied the utility of detecting SLN with computed tomography (CT) lymphography in those with tongue cancer. MATERIALS AND METHODS: Subjects numbered 12 with T1 or T2N0 tongue cancer. After 2 ml of iopamidol was injected peritumorally, CT was conducted at 1, 3, and 5 minutes after injection and SLN identified and marked on the day before surgery. SLN was examined pathohistologically by frozen section. RESULTS: SLN was identified in all but one case. SLN metastasis was found in one case each of T2N0 and T1N0. CONCLUSION: CT lymphography in SLN detection of tongue cancer is simple and useful because the anatomical relationship of tumors, lymphvessels, and SLN could be determined preoperatively.
We report a case of oral-floor thyroglossal duct cyst. A 29-year-old woman seen for an oral-floor tumor and slight dysphonia. The tumor, diagnosed as a cyst in magnetic resonance imaging (MRI), was resected from the oral side. The pathologic diagnosis was a thyroglossal duct retention cyst, a very rare condition.
Subjects with ingected or otherwise internalized with foreign bodies often require emergency aid, especially in cases with tracheobronchial foreign bodies causing respiratory compromise and potentially mortal pneumonia. We treated 18 such cases in the last 20 years—8 men and 10 women—half of whom were one year old. Most objects were beans or nuts initially evidencing cough and stridor, with some involving pneumonia and/or atelectasis, successfully removed in ventilation bronchoscopy. Half of foreign bodies were found in the left main bronchus, and eight showed Holtzknecht’s sign in chest X-ray imaging.