In this panel discussion, we defined intractable otitis media characterized by a gelatin-like fluid in patients suffering from bronchial asthma of adulthood onset as suspected “eosinophilic otitis media.” When the presence of a significant infiltration of eosinophils is observed in the granulation tissue or middle ear effusion, such otitis media is ascertained to be “eosinophilic otitis media.” Eosinophilic otitis media may occur in patients with or without any type of bronchial asthma. However, elucidate this middle ear pathology, we limited our discussion to adult patients suffering from bronchial asthma in adulthood. Gelatin-like fluid is one characteristic feature of such otitis media. In some cases, serous effusion is initially observed before its replacement by a gelatin-like fluid. Treatment for serous otitis media, such as insertion of a ventilation tube, results in temporary relief, and tympanoplasty is rarely effective due to mucosal abnormality. Progression of otitis media in these patients is controllable with steroid therapy, although control in advanced cases is difficult, even with such therapy. Sensorineural hearing loss is the complication of eosinophilic otitis media which physicians should be most concerned about. Mixed hearing loss gradually worsens despite long-term treatment, sometimes resulting in total deafness in severe cases. Given the high complication rate of sensorineural hearing loss and the different therapy needed in these cases, it is important that eosinophilic otitis media be discriminated.
Despite an increasing number of reports of so called 'eosinophilic otitis media', its nature and pathogenesis are not fully understood. This surveillance was performed in an attempt to investigate the clinical and epidemiologic characteristics of eosinophilic otitis media. Definite diagnosis was made according to the following four criteria:(a) adult patients with bronchial asthma, (b) extremely viscous middle ear effusion, (c) resistant to usual treatments such as antibiotics, myringotomy, tympanostomy tube insertion, tympanoplasty, etc., and (d) marked eosinophil infiltration in middle ear effusion and/or middle ear mucosa/granulation. Patients who met the first three criteria were judged as suggestive cases. We sent the primary questionnaires to 1409 hospitals and medical universities all over Japan in which full-time ENT doctors work, and received answers from 628 hospitals. Three hundred and forty-one definite and 446 suggestive cases were presented. The secondary questionnaires were sent to 137 hospitals to survey the details of the presented definite cases. The disease was predominant in females in their fifties and sixties. Both ears were affected in 81%, and sinusitis was associated in 74% of the patients. Forty-seven percent of the patients had sensorineural hearing loss, and 6% were deaf. The ratio of sensorineural hearing loss was not dependent on the history of sinus surgery (49% vs. 46%, p>0.1). Topical and systemic steroids were used in 78% and 66% of the patients, respectively. The ratio of sensorineural hearing loss was significantly higher in patients who were given systemic steroids than those without systemic steroids (52% vs.34%, p<0.05). Only13% of the patients underwent tympanoplasty, and showed significantly higher ratio of deafness compared to those without tympanoplasty (17%vs.4%, p<0.05). Sensorineural hearing loss was exacerbated postoperatively in most of the deaf patients who underwent tympanoplasty. These results demonstrated intractable features and poor prognosis of hearing of eosinophilic otitis media.
How to provide education and training in middle ear surgery, then evaluate the surgical skills obtained is discussed. To become an independent skillful surgeon, there are some important objectives in the middle ear surgery that need to be learned; preoperative diagnosis and local treatment, safe and reliable procedures during the operation, and careful postoperative local treatment. At the time of the middle ear surgery in the operating room, appropriate handling of the microscope, endoscopes, power drill and facial nerve monitor is a very important set of skills to be evaluated. The practice of otological procedures on cadaver temporal bones is also an unavoidable training technique in acquiring middle ear surgical skills.
Virtual reality (VR) will have a major impact on surgical education in the future. It is emerging technologies that can educate students and resident the new surgical procedures. VR might be used to further enhance medical education and assist in the surgery of a variety of diseases. High performance medical image processing is to play an important role in surgical planning and VR simulator can realize quantitative and/or qualitative measurement of competence by using surgical manipulation data. In the present, various surgical educations using virtual reality technology are discussed, along with the technological developments needed to make them possible.
Recent studies have shown that there is a gas exchange function between middle ear cavity and blood vessels through middle ear mucosa, and the function plays a very important roll on the regulation of middle ear pressure, however there is few reports to evaluate the relationship between the function and morphological characteristic of middle ear cavity. The relationship between the transmucosal gas exchange function and the surface area and volume of middle ear cavity was investigated. The subjects were ten patients who underwent myringoplasty with dry tympanic membrane perforations without active inflammation in the middle ear cavity. At the time of operation under general anesthesia with the inhalation of nitrous oxide, increasing middle ear pressure caused by the diffusion of nitrous oxide was measured, and the gas exchange function was quantitatively evaluated. Surface area and volume of middle ear cavity were measured by CT scans. The strong correlations between the gas exchange ability and surface area, and the surface area and volume were confirmed. Human middle ear cavity had a large surface area corresponding to its large volume by having air cell systems, and the gas exchange function through the middle ear mucosa depended on the surface area. The morphological characteristic of the middle ear cavity is of great advantage to regulating middle pressure by transmucosal gas exchange function.
Objective: Investigations using otoacoustic emissions have great potential to detect cochlear impairment, especially nonlinear mechanical functions of the outer hair cells. Distortion product otoacoustic emissions (DPOAE) mostly reflect audiometric thresholds; however, there could be an inconsistency between DPOAE response and audiometric thresholds depending upon the pathologic lesion. The objective of the present study is to assess the effects of aging and generalized diseases on auditory function using DPOAE after adjustment of confounding factors including audiometric thresholds. Subjects and method: Of 1534 participants in a population-based study, 1265 subjects aged between 41 and 82 years who were administered DPOAE and other auditory tests were selected for the present analysis.Loss of DPOAE was defined as a signal-to-noise ratio of DPOAE amplitude equal or less than 0 dBSPL. Statistical analysis according to sex was performed in order to identify factors associated with loss of DPOAE using a multiple logistic regression model in which the independent variables were age, hypertension, hyperlipidemia, diabetes mellitus, ischemic heart disease, renal disease, liver disease, pure-tone average of 5 frequencies, resonant frequency of middle ear, ear disease, smoking habit, and occupational noise exposure. Results: Age (odds ratio [OR] per 10 year=1.36, 1.40, 1.53, at f2=5188, 5652, 6165 Hz, respectively, in male and OR=1.32, 1.52, 1.42, 1.57, 1.46 at f2=1001, 1086, 4004, 4358, 6165 Hz, respectively, in female), presence of ischemic heart disease (OR=2.25, 2.61 at f2=2002, 2185 Hz, respectively, in male), presence of hyperlipidemia (OR=1.89 at f2=4358 Hz in male) and presence of liver disease (OR=2.55 at f2=3662 Hz in female) showed a significant statistical association with loss of DPOAE. Conclusion: Aging, ischemic heart disease, hyperlipidemia, and liver disease each may have an independent influence on auditory function from the effects on the pure-tone thresholds.
The Combi40+ cochlear implant device manufactured by MED-EL has such advantages as having a long electrode with 12 channels which can be inserted deep into cochlea and being capable of a very fast stimulation using CIS coding. This device is widely adopted all over world, especially in Europe. We implanted this Combi40+ device into the cochleae of four postlingually deaf adults and reported the results in the early period. No postoperative complication was observed for about one year. The speech comprehension ability was comparable to other devices of the different manufacturers, and the patients expressed a high degree of satisfaction with the cochlear implant. We consider that the Combi40+ device is as safe and efficient as the other devices currently employed in our country.
Of 181 unilateral acoustic neuroma cases investigated in Niigata University Hospital during 1990-2002, 7 cases (3. 9%) with normal pure-tone audiometry threshold were presented. The chief complaints which lead to the diagnosis of acoustic neuroma were tinnitus in 2 cases, headache in 2 cases, facial pain in 2 cases and vertigo in 1 case. The tumor size of 5 cases ranged from 15mm to 50mm in maximum CP angle diameter, on the other hand, only 2 cases showed intracanalicular tumor. The normal hearing did not guarantee small acoustic neuroma. The auditory brainstem response abnormality was observed in 5 cases (70%), which was most sensitive otoneurological test examined. Presented 7 cases showed normal pure-tone thresholds, not exceed 20 dB in both ears. However, precise comparison of the affected ear threshold and the other side in each frequency of each case showed deterioration in the affected ear at one or two frequencies, which might be a clue to diagnose normal hearing acoustic neuroma. Among the 7 cases examined with MRI imaging, 4 cases were examined by 3DFT-constructive interference in steady state sequence, which revealed that the fundus of internal auditory canal (IAC) was not obliterated by the tumor. The tumor obliteration in the IAC fundus may related with the hearing deterioration in acoustic neuroma.
Pharyngeal orifice of the eustachian tube was ligated in 6 patients, 8 ears withintractable patulous eustachian tube. While the eustachian tube orifice was observed by an endoscope inserted through the contralateral nostril, the orifice was ligated transnasally and/or transorally using instruments usually used in the endoscopic nasal surgery. Now 1 to 6 months after the surgery, the outcome was excellent (both symptoms and sonotubometry were normalized) in 3 ears, good (either symptoms or sonotubometry was improved) in 3 ears, and unchanged in the remaining 2 ears. In one of the ears with an outcome of unchanged, the ligation was found to be spontaneously released soon after surgery, but the symptom was improved after the second operation 2.5months after the first operation. Temporary otitis media with effusion was seen in one ear, and mild inflammation around the ligated site also in one ear, but no other serious complication has been observed. Although further improvement in the surgical procedure and further discussion about its longterm outcome should be required, this procedure appeared to be one of the therapeutic options for intractable patulous eustachian tube.
In 2000, a new classification system of ossicular reconstruction was proposed bythe terminology committee of Otological Society of Japan. Of the ossicular reconstruction, the type III tympanoplasty is a most common procedure. In this article, we evaluate the hearing results after the type III stapes columella tympanoplasties (III-c) and the type III incus interposition tympanoplasties (III-i) that were performed in our division. Total subjects were 128 patients who received either III-c (84 cases) or III-i (44 cases) and had subsequent follow-up period not less than 6 months. Favorable hearing results were observed in 77.3% of the patients who underwent III-c, and 79.5% of III-i. Furthermore, the comparison and evaluation of these data with the hearing results after the type IV tympanoplasties are shown.
In seven patients visited Kyushu University Hospital over a period of 3 years and 8 months the temporal bone was destructed around the jugular foramen. Their clinical manifestations and findings were examined and the importance of the diagnosis of these lesions was discussed. There were three males and four females, ranging in age from 27 to 61 years (average: 48) old. In addition to the usual physical examination, the neurological evaluation included pure tone audiometry, electronystagmography when there was a subjective feeling of imbalance, and video fluorogram of the pharynx for estimating the lower cranial nerves function. The extent and characteristics of the lesions were investigated using temporal and facio-cervical CT and MRI. Histological examinations were used to verify the diagnosis. In two cases a tumor extended into the external auditory canal, and specimens were taken after cutting the covering skin under local anesthesia. Deep masses were excised using a transmastoid approach under general anesthesia. The seven lesions consisted of three benign tumors, two primary malignant tumors, one metastatic tumor, and one cholesterol granuloma. Three of the seven cases were presented in detail. Although English literature reported a high incidence of glomus tumor, our series included only one. Although the clinical manifestations and imaging studies were useful for the differential diagnosis, pathohistological examination was necessary for the definitive diagnosis. Since transmastoid approach gives a wide operative field, it enables a sure and safe biopsy, and is preferable to myringotomy for biopsy. Three of our cases were malignant. The relatively high rate of malignancy suggested the need for biopsy, even when the symptoms were minimal. The clinical manifestations and image findings cannot rule out the possibility of malignancy.
From November 1993 to March 2003, 23 ears with postoperative hearing impairment were reoperated in our hospital. Cases with otorrhea, and cholesteatoma detected preoperatively was excluded from this study. All 23 ears underwent the initial operations in other hospitals, and surgical information was not obtained in 17 patients. The interval from initial operation and reoperation was ranged from 12 months to 40 years, and only 4 ears were included in the group who were operated initially in the recent 5 years. Type IQ tympanoplasty for 13 ears and type IV tympanoplasty for 8 ears were performed. Total stapedectomy was performed for one ear in which the stapes accidentaly removed. Success rates of hearing improvement were 76.9% of type III tympanoplasty, and 62.5% of type IV. Success rate of all 22 ears exept for one case unable to follow was 72.7%. Complications such as facial paralysis, vertigo, deafness, and intracranial complications were not observed in all cases. Preoperative functional examinations of hearing impairment and image examinations (CT) are useful for postoperative ears.
Auricular swelling is seen in auricular hematoma, pseudocyst, chondritis, atheroma, and infection of ear fistula and others. Auricular hematoma mostly occurs in the superior anterior part of the auricle after a certain trauma, and blood is aspirated with puncture. However, we recently experienced 9 cases (a total of 10 auricle) of auricular swelling in which there was no obvious past history of trauma and the serum was aspirated by puncture. The patients visited our clinic 5 days, on the average, after first recognition of the swelling. In all cases except one, a soft swelling was observed between the antihelix and concha and the symptom was relatively mild without severe pain. In all cases, small amount of the rose-wine colored or straw-colored serum (0.2-1.0ml) was aspirated by puncture. In most cases, serum accumulation reappeared after the first aspiration, and further twice or 3 times of aspiration of serum were required. Characteristics of these 9 cases are summarized such as 1) no obvious past history of trauma, 2) accumulation of small amount of the rose-wine colored or straw-colored serum, 3) site of predilection is in between the antihelix and concha, 4) no remarkable sign of inflammation or severe pain, 5) disappearance without marked fibrous tissue proliferation. The term auricular seroma seems to be more appropriate to these conditions. There are few reports about the auricular seroma, and the definition of auricular seroma has not been clearly settled. We advocate that an auricular seroma should be treated as an independent disease entity that is different from other auricular swelling, such as auricular hematoma or pseudocyst.
Congenital otorrhea of cerebrospinal fluid (CSF) is usually accompanied by Mondini-type inner ear malformation, in which CSF leaks through the oval window. It is very difficult to find CSF fistula when CSF leaks through outside the oval window. The first case was a 5-year-old boy who developed recurrent meningitis twice a year. Neither audiogram nor tympanogram showed abnormal findings bilaterally. CT scan of the temporal bones and MR-hydrographm demonstrated a little effusion in the right mastoid, but neither evidence of CSF leakage nor bony defect. However, RI-cisternography revealed an abnormal accumulation of radioisotope in the right middle ear, thus he was diagnosed as leakage of CSF. Exploratory tympanotomy of the right ear uncovered a bony defect just inferior to the fallopian canal, suggesting CSF fistula at the region of the geniculate ganglion. The second case was a 6-year-old girl who had suffered from Langerhans cell histiocytosis, developed bacterial meningitis twice. Audiogram revealed right deafness and CT scan of the temporal bones showed right common cavity malformation. RI-cisternography revealed no abnormal accumulation of radioisotope. Although there was no sign for CSF otorrhea, exploratory tympanotomy of the right ear disclosed a little amount of CSF leakage through the Hyrtl's fistula.
Trisomy 13 has multiple physical anomalies.The aural malformations are also various.To date, a review of the literature showed 18 reports of the histopathological changes affecting the temporal bone in patients with trisomy 13.In this report, histpathological findings of the temporal bone of a fetus with trisomy 13 are described. The first case, 35 weeks male, had multiple malformations in the middle and inner ears.The inner earpresented Mondini type dysplasia. The second case, 21 weeks female, had also Mondini type inner ear dysplasia.Disorders of two cases are regarded as viviparity eight weeks in embryology.Inner ear malformations of trisomy 13 is variouly from mild to severe, and it seems to be difficult to classify. Radiological evaluation of malformed classification in trisomy 13 will become useful in the future.
We experienced two cases of surfer's ear, exostosis of the external auditory canal, and one of them developed acute mastoiditis and the other with traumatic eardrum rupture. In both cases, extreme stenosis of the external auditory canal was observed. In the former case, the patient complained of left temporal pain for a month. The external canal was completely closed and the eardrum could not be observed. Emergency mastoidectomy was necessary because exposure of the posterior fossa dura by the inflammation in the left ear was suggested by CT findings. In the latter case, the patient had frequent vertigos during surfing after a trauma by a wave in the right ear. Observation of the eardrum perforation was difficult even under a microscope. After the removal of exostosis, the whole perforation was confirmed and myringoplasty was performed. Removal of exostosis in the advanced case is necessary even if no symptoms are found because of the diagnosis delay of the serious complication derived from the canal stenosis.