Increase in methicillin-resistant Staphylococcus aureus (MRSA) infection has been a serious issue in otorhinolaryngological practice. It is still controversial how to cope with this condition. The outcome of tympanoplasty performed on MRSA infected chronic ears was studied. Eighteen ears operated from January 1997 to April 2000 were analyzed. These cases included 12 ears with chronic suppurative otitis media, 5 ears with cholesteatoma and 1 ear with adhesive otitis media. MRSA was detected in all cases prior to surgery. It was confirmed that the MRSA was sensitive to vancomycin (VCM) and arbekacin (ABK). After surgery VCM, ABK, minocycline or teicoplanin was administered with cephem or broad spectrum penicillin in most cases. The post-operative course was uneventful in 16 out of 18 ears which resulted in well healed dry ear drum. Regarding the remaining 2 ears, otorrhea occurred after surgery which could be controlled by repeated local lavage and administration of antibiotics. Our keys for surgical success are, topical lavage before and after sugery, administration of appropriate antibiotics, usage of pedicled flaps for canal reconstruction and eradication of the disease.
Thirty nine cases of acute mastoiditis admitted to Kitasato University Hospital over the past 30 years (1971-2001) were reviewed. Twenty six of the patients were younger than five years old. Twenty eight cases required surgery for control of inflammation. The clinical features were compared between those cases required mastoid surgery and those treated without surgery. Those cases treated surgically, visited our hospital over 10 days after the onset of symptoms, and clinical findings were a retro-auricular swelling and erythema in 25 cases, protrusion of the auricle in 15, and a swelling in the posterior wall of the external audiotory canal in 8. In the 28 cases treated surgically, simple mastoidectomy was performed in 24 cases, radical mastoidectomy in 2 cases, and atticotomy and simple mastoidectomy in 1 case, and exploratory mastoidectomy in 1 case. During surgery, cholesteatoma was recognized in 3 cases out of the 28. Eleven patients treated with antibiotic therapy without mastoid surgery, and myringotomy followed by insertion of a ventlation tube was necessary in 4 cases out of the 11. In those cases treated without mastiodectomy, subperiosteal abcess was found in only 3 of the 11 cases, while it was found in 25 of the 28 cases treated with mastoid surgery. When subperiosteal abcess was absent, the initial treatment was antibiotic therapy. When there were 3 findings of a swelling in the retro-auricular region and the posterior wall of the external auditory canal, and protrusion of the auricle existed, mastoid surgery was considered to be the initial treatment.
In the patients with a patulous eustachian tube, disappearance of annoying aural symptoms such as autophony, sensation of fullness and hearing of respiration sound can be noticed in a supine position. In this study, we measured pure-tone thresholds both in sitting and supine positions in patients with patulous eustachian tube. Out of 19 ears of 14 patients, improvement in auditory threshold mainly in low frequencies was observed in 13 ears (68%) in a supine position. Among the 13 ears with hearing improvement, 7 showed disappearance of aural symptoms of patulous tube while two showed no change. Although the improvement of hearing threshold in response to the postural change to a supine position was not detected in all patients, the knowledge of this phenomenon seems to be helpful for diagnosis and evaluation of the effect of treatment in patients with patulous eustachian tube.
We experienced 2 cases of perilymph gusher during cochlear implantation. The gusher was easily stopped by sealing cochleostomy with soft tissue in a patient with internal auditory meatus malformation, whereas the mesotympanum, attic and antrum were obliterated with soft tissue in another with the common cavity type malformation. Both patients had no postoperative complications, and the cochlear implantation helped their hearing. We experienced two other patients with inner ear malformations in whom perilymph gusher did not occur during cochlear implantation. One of them had the incomplete partition type cochlea, and the other had the common cavity type malformation. By comparing the CT and MRI findings in patients with perilymph gusher and those without it, we discussed whether it is possible to predict the occurrence of perilymph gusher or not.
We experienced a case of medial meatal fibrosis, which is a rare entity linked to inflammatory and traumatic factors. A 25-year-old woman suffered from hearing loss in both ears. She had developed graft-versus-host disease (GVHD) following bone marrow transplantation for the treatment of chronic myelogenous leukemia 7 years ago. As a sign of GVHD, she had had chronic external otitis for 4 years, and her hearing had deteriorated gradually. On otoscopic inspection and computed tomographic examination, the tympanic membranes were found to be thickened and lateralized, but no abnormalities were observed in the middle ears in both sides. She underwent meatoplasty bilaterally. After removing the postinflammatory connective tissue in the external ear canal and thickened lamina propria, the raw surfaces were covered with skin grafts. Postoperatively, the hearing became normal, and no recurrence had been observed for 2 and half years.
Catecholamine secretion from glomus jugulare tumor is uncommon. A 23-year-old male complained of dizziness without tinnitus and hearing impairment in the right ear. Red color mass in the right hypotympanum was observed through the tympanic membrane. Preoperative MRI revealed a hyper-vascular mass between the jugular bulb and the internal carotid artery and the diagnosis of glomus jugulare tumor was made. Preoperative data showed normal blood pressure and no tachycardia. The patient was received an intra-arterial embolization treatment before 48 hours of the surgery to reduce bleeding from the tumor during surgery. But just after the feeding arteries to the tumor were embolized, the patient had an attack of hypertension crisis that was 240mmHg at maximum blood pressure. Usual blood pressure of the patient was 120/70mmHg. The tumor was completely excised with large blocks and piecemeal by an infratemporal fossa approach. Intraoperative blood pressure was well controlled at 130 to 140mmHg. One of hypotensive drugs, calcium blocker, was given postoperatively for five days because of the high level of plasmocatecholamine. The patient had a good postoperative course. Incomplete facial palsy in the right side was completely recovered until four postoperative months. Embolization treatment for the glomus tumor was considered to be useful not only for the reduction of bleeding but also the detection of functioning tumor. Routine screening of Catecholamine was indispensable before surgery.
A 57-year-old female had undergone middle ear surgery for otitis media in the right ear 27years ago. Since then, she had occasional right aural discharge and persisted mild sensorineural hearing loss with conductive loss in the right ear. She was diagnosed as having otitis media with cholesteatoma and total removal of cholesteatoma was attempted in another private hospital. In this operation, it was found a squamous epithelium invaded the intracranial space of middle fosa, and cerebrospinal fluid (CSF) leakage was encountered. So she was referred to Otolaryngology clinic of Osaka University. Totol removal of subdural cholesteatoma was performed and dural plasty at the dural dehiscence was done. It thought three ways to make fistula at the dura mater, in spite of its biologic and physical tenacity; Iatrogenic disease that epithelium was implantation through the dural dehiscence when the operation was performed 27 years ago, Progressive inflammation of the dura mater was induced by necrotoxic effects of bacterial growth, cPressure atorophy of the dura mater by expanding cholesteatoma.
Tinnitus is a benign disease, but it may have a serious impact on quality of life (QOL). To date, there is no specific treatment in modern medicine and sometimes the results of the treatment of tinnitus are discouraging. We report a satisfactory clinical result in the treatment of tinnitus by acupuncture according to Traditional Chinese Medicine (TCM). A male patient, with sudden onset idiopathic Sensorineural hearing loss with severe tinnitus of the left ear, had no marked improvement in clinical symptoms after conventional treatment including systemic administration of vitamins, adenosine triphosphate, prostaglandin I2 and two courses of hydrocortisone pulse therapy. Subsequently, one cycle of acupuncture treatment was performed for the spleen-stomach deficiency and endogenous damp-turbidity based on the TCM diagnostics and during the period of treatment, tinnitus decreased stepwise from the level of 8000Hz, 8 dB prior to the treatment to 0 dB SPL, according to a tinnitus audiometer (Danac-100, Dana Japan). Although there was no significant improvement in hearing loss, the patient felt marked relief from tinnitus, the so-called buzz bomb in the ear. From this result, acupuncture based on TCM may be available for the treatment of tinnitus.