The initial steps of attic cholesteatoma formation has never been documented. Therefore, the true cause of this disease remains only to be speculated. The most frequently suggested hypothesis is the migration theory. In order to clarify the conditions concerning the pathogenesis of attic cholesteatoma, the present study was conducted to search for predisposing factors for the development of this disease by way of clinical statistics and observations of the formation of, cholesteatoma in experimental animals. An analysis of patients with attic cholesteatoma and of their courses after posterior tympanotomy has revealed that a majority of cases have a history of acute or secretory otitis media in childhood, an extremely sclerotic mastoid process which is suggestive of a genetic disposition, intratympanic negative pressure, and occlusion of tympanic isthmuses by fibrous or granulation tissue. Experimental cholesteatoma in guinea pigs can be produced behind an intact tympanic membrane by injections of Glycerin into the middle ear. This viscous fluid cause eustachian tube obstruction, negative middle ear pressure, and middle ear inflammations. The cholesteatoma develops as a result of the proliferation of basal cells of the epidermis of the external auditory meatus or the tympanic membrane, growing into the granulation tissue which has formed in the middle ear space. The conditions related to the etiology of attic cholesteatoma formation implied by the above observations are:(1) inflammatory changes around the ossicular chain ;(2) negative pressure in the attic, and (3) chronic dysfunction of the eustachian tube associated with incomplete pneumatization.
Over the past 10 years we have successfully isolated and identified 2658 strains of bacteria from middle ear otorrhea. Broadly classified, 1698 gram-positive cocci (63.8%), 822 gram-negative bacilli (30.9%), and 138 other strains (5.2%) were detected. Staphylococcus aureus and Pseudomonas aeruginosa accounted for the majority of gram-positive cocci (50.9%) and gram-negative bacilli (57.8%), respectively. S. aureus was detected most frequently (37.0%) in cases of acute otitis media. In recent years, S. aureus has surpassed the identified number of pneumococcal and hemolytic streptococcal strains, highly prevalent in past years. However, pneumococci and hemolytic streptococci continued to be frequently found in children under 6 years of age, while S. aureus was most often isolated from children of age 6 and over. Among 2813 strains isolated from cases of chronic otitis media, S. aureus accounted for 31.8%, Ps. aeruginosa for 19.2% and S. epidermidis for 17.0%. Comparison of yearly fluctuations revealed the detection rate to be unchanged for S. aureus and reduced from 25% in 1963 to 16% in 1972 for Ps. aeruginosa. S. aureus and Ps. aeruginosa were more frequently detected in cases undergoing surgery than those not. Mixed infections were present in 11.8% of patients with acute otitis media and 38.6% of patients with chronic otitis media. Diptheroids were related to mixed infections in many patients and were found along with another type of bacteria in 95% of postoperative cases. Substitution of the bacterial flora occurred about twice as frequently in postoperative cases than in those not operated on. The type of bacterial substitution was varied, but there was a tendency towards a transition from gram-positive cocci to gram-negative bacilli. Drug sensitivity was determined using discs containing 3 drug concentrations. Susceptibility was higher than that in other reports. Although (+++) and (++) sensitive bacteria were regarded to be effective, clinically it is more reliable to consider (+++) sensitive bacteria as being susceptible. Sensitivity tests were carried out for S. aureus and Ps. aeruginosa. S. aureus was highly sensitive to cephaloridine and chloramphenicol. Hemolytic streptococci and pneumonocci were highly sensitive to every drug tested. Ps. aeruginosa exhibited high susceptibily to colistin and gentamicin. Colistin was effective for all gram-positive bacilli tested except Proteus and Proteus inconstans.
The authors report a follow-up study on the long-term results of vidian neurectomies performed during the past 10 years at the Jikei University School Hospital. In the previous study on 71 cases the subjective effectiveness turned out to be 94.4% while the present study showed 97.7% subjective effectiveness both of which are similar with the results reported by others. Recurrence of milder symptoms in some cases several years after neurectomies was also confirmed by the present study. The authors discuss reinnervation and regeneration of the autonomic nerves and denervation hypersensitivity as the probable causes of the recurrence of the symptoms.
A case of postoperative ethmoidal cyst with conspicuous exophthalmos and blindness is reported. Clinical manifestations were studied on twenty cases of postoperative paranasal sinus cysts other than postoperative maxillary sinus cyst. In these cases, ethmoidal cyst was most frequent and many had visual disturbances. The CT scanning seemed to be useful for diagnosis of postoperative ethmoidal cysts. In young patients paranasal sinus cyst was likely to be formed shortly after paranasal surgery. Finally, the importance of extra-nasal surgery in these postoperative paranasal sinus cysts with visual disturbances is discussed.
A 72-year-old male with extramedullary plasmacytoma in the hypopharynx is presented. The patient had a history of total gastrectomy for stomach cancer without recurrence, and developed swallowing disturbance and hemoptysis 3 days before his admission. Laryngoscopic examination revealed a large mass in the posterior wall of the hypopharynx. Laboratory examinations showed an increase in Ig A, slight increase in Ig G, and decrease in Ig M and Ig E. Immunoelectrophoretic studies of the serum protein revealed an increase of Ig A type M-component. The light and electron microscopic studies of the biopsied specimen demonstrated densely packed rather well differentiated plasma cells and a scant connective tissue stroma. The tumor was completely extirpated by para-pharyngectomy, but immunoelectophoretic studies of the extract from this growth was found to be Ig G (type K) myeloma which was incompatible with the preoperative diagnosis. It was thought that this patient had essential or secondary monoclonal gammopathy other than solitary extramedullary plasmacytoma of the hypopharynx.
The author has devised a new pharyngo-laryngeal forceps for the removal of pharyngolaryngeal foreign bodies, especially fish bones. The forceps is 23.5 cm long with a 90° curve. The tip of the forceps is flat, 1 cm long, and 3 mm in width. The forceps should be held as shown in the photograph. Using this pharyngo-laryngeal forceps, foreign bodies in the pharynx, pharyngeal portion of the tongue, vallecula epiglottica, and piriform fossa can be removed very easily, even in an active 6-month-old baby.