Pathophysiology of the gas exchange function of the middle ear mucosa after surgery, efficacy of a largesized silicone film upon recovery of mastoid aeration after mastoidectomy, and indication of mastoid obliteration in combination with the “soft-wall reconstruction” of the posterior ear canal wall were described. The mucosa in the middle ear, especially in the mastoid, has gas exchange function, contributing to the pressure regulation in the middle ear, but the function is usually lost after mastoidectomy. Placement of a large-sized silicone film covering from the eustachian tube to the mastoid antrum after mastoidectomy helped recovery of mastoid aeration in more than half of the patients. Particularly, when a tympanostomy tube was placed in addition to it, the recovery rate was better. Since the posterior canal wall retracts towards the mastoid after mastoidectomy in patients being operated with the soft-wall reconstruction of the posterior ear canal wall, mastoid obliteration with a smooth material such as bone pate is recommended in case of one-stage operation when the mastoidectomized cavity is large. Whereas, in two-stage operation, even if the cavity is large, placement of a large-sized silicone film is worth being tried expecting recovery of the mastoid aeration.
Pneumatization of the middle ear cavity is important for managing the cholesteatoma and adhesive otitis media. Severely diseased ears have little pneumatization and consequently the dysfunction of the sound conduction system. The ventilation through the Eustachian tube and the gas exchange through the middle ear mucous membrane control the pneumatization of the middle ear cavity. The Eustachian tube mainly works for ventilating the middle ear cavity. To achieve the inflammation free middle ear and good sound conducting condition, we need the pneumatization minimally in the mesotympanum. From our thought, it is difficult to make a big pneumatized cavity by operation in these severely diseased cases. We introduce our operative method for making the minimum pneumatized cavity in the mesotympanum. Our operative method is the canal wall down but closed method tympanoplasty with intact canal skin method and with the canal reconstruction by attic, antrum and mastoid obliteration using bone pate. Using silicone plate, the mucous membrane in the Eustachian tube has been induced to the mesotympanum. We think that the success of tympanoplasty for adhesive otitis media is to succeed to reconstruct the pneumatization in the mesotympanum. We show our results of operation and discuss about our operative methods.
The aim of this clinical study is to develop the new treatment for intractable otitis media such as adhesive otitis media, severe cholesteatoma, and so on. Poor development of mastoid cavity and its air cells is often observed in chronic otitis media patients. The functions of the mastoid air cells had not been found for a long time. Recent studies, however, reported that the mastoid air cells had the gas exchange function through their blood capillaries in mucosa covered over the wall of mastoid air cells. This system and the Eustachian tube function keep the middle ear cavity an adequate pressure. Therefore, failure of this system is thought to prevent chronic otitis media from recovery. In this study, we tried to regenerate the pneumatic air cells and their gas exchange function in the patient with chronic otitis media. Eighteen patients (8 males and 10 females) were randomly selected from chronic otitis media patients with cholesteatom (n=10), cholesteatoma with adhesive otitis media (n=5), and severe chronic otitis media (n=3). Patients ranged in age from 5 to 85 years. All but one patient, with severe chronic otitis media, underwent both stages of the two-staged operation. These patients were divided into two groups. Group I (n=5) was performed the regenerative operation and the usual mastoidectomy. Group II (n=13) was performed the regenerative operation and the mastoidectomy with the mastoid cortex bone plasty. The followup period was from 9 to 12 months after the second-stage of tympanoplasty. Hydroxyapatite of honeycomb-like structures was made and used as a framework for artificial pneumatic bones. This artificial material with a high macropore ratio of 90 % was mainly composed of calcium phosphate. And its surface was coated with collagen from porcine skin to promote mucosal cells attachment. At the first-stage of tympanoplasty, collagen-coated HA was implanted into the newly opened mastoid cavity and was fixed by fibrin glue in the both groups. After the first operation, recovery of mastoid aeration and regeneration of the pneumatic air cells of the newly opened mastoid cavity were assessed on high resolution CT scan images. At the second-stage operation, the cortex bone of the mastoid was observed to be perfectly regenerated in all cases in group II. At the second-stage operation, regeneration of the pneumatic air cells in the mastoid cavity were observed in 3 of 17 cases, but in remained 14 cases, soft tissues and/or effusion were observed in the mastoid cavity. After removing the obstacles for communication between the both mastoid and tympanic cavity, in 14 of 18 cases (77. 8%), aeration was recovered and in 10 of 18 cases (55. 6%), honeycomb-like structures were regenerated by the final assessment. In all cases in group I, connective tissues grew into the micropores of implanted artificial pneumatic bones, and no aeration was observed in the mastoid cavity at the second-stage operation. This study demonstrated that the mastoid air cells could be regenerated with implanted artificial pneumatic air cells in the newly opened mastoid cavity with intractable chronic otitis media patients. The mastoid cortex bone plasty was effective in regeneration of the mastoid air cells by prevention of connective tissues invasion to the mastoid cavity. This tissue engineering method may be a possible treatment for intractable otitis media because of recovering the gas exchange function of the mastoid air cells.
Facial nerve defects are frequently produced as complications of surgery or due to trauma. In such cases, the facial nerve is repaired with an autograft. However, this procedure has many disadvantages, including donor site morbidity, sensory loss, and incomplete regeneration. This study evaluated the functional and histological regeneration of the facial nerve in adult guinea pigs after repair with autogenous or collagen nerve grafts, with or without laminin and bFGF. The artificial nerve is made of an atelocollagen tube containing atelocollagen fiber and sponge (NIPRO, Japan). The facial nerve was resected (10-mm segments) to create nerve gaps in four groups of animals in order to compare the histological and functional outcomes: Group A (n=6): autologous nerve interposition graft, Group B (n=6): collagen nerve guide, Group C (n=3): collagen nerve guide with bFGF, and Group D (n=3): collagen nerve guide with laminin. Electron microscopical and electrophysiological examinations were performed 6 weeks after the nerve grafts. The results of conduction velocity tests showed excellent nerve regeneration in Groups A and C. Regenerated nerve fibers were observed in both groups using electron microscopy, and the axonal diameter and myelinated nerve sheath were thicker in Groups A and C than that in the other groups. The results of this study suggest that an atelocollagen nerve guide filled with bFGF is at least as good as autologous nerve grafts for bridging 10mm facial nerve gaps. However, further research is necessary before this procedure becomes widespread.
We studied on long-term outcome of patients with sudden deafness between 1972 and 1999. We investigated specific cases that have been followed longer than five years at Kitasato University Hospital. Twentyeight cases (18.3%) out of 153 showed some changes in hearing level during the observation period. All of the changes noted to be deterioration. We then divided these 153 cases into two groups: the one with the hearing deterioration and the one without. There appeared to be no significant difference in terms of sex, age, balance disorder, the grade of hearing level at the onset, the degree of recovery in initial presentation, and Jerger type in Bekesy audiogram between these two groups. The affected side of the ear tended to show more deterioration of hearing than non-affected side. We speculate that there may be a progressive nature in sudden deafness in a long-term period.
Eosinophilic otitis media (EOM) is an intractable otitis media characterized by persistent viscous middle ear effusion and granulation tissue in the middle ear. Patients with EOM often have adult-onset bronchial asthma. Some of these patients show severe and progressive sensorineural hearing loss as well as conductive hearing loss. Despite an increasing number of reports of EOM, its nature and pathogenesis are not fully understood. This study was performed to investigate the clinical and epidemiologic characteristics of EOM. Forty-two patients who had adult-onset bronchial asthma were enrolled in this study. Seventeen (40.5%) patients had nasal allergy, and 15 (35.7%) had bilateral nasal polyps. Concerning ear diseases, 17 patients, 29 ears (34.5%), had abnormal findings on their eardrums and 5 of these patients (10 ears, 11.9%) had EOM. In these 5 patients diagnosed of EOM, 4 patients had non-atopic bronchial asthma and 4 patients also had aspirin intolerance. These results suggest that carerful observation of ears is necessary for patients with adult-onset bronchial asthma, especially when the asthma is non-atopic or when they have aspirin intolerance.
Ninety-three cases of tympanoplasty in Osaka Medical College for three and half years were evaluated. Mainly cortical bone and tragal cartilage were used in ossiculoplasty. Successful result was obtained in 21 (95%) of 22 ears with tympanoplasty type I, in 49 (88%) of 56 ears with tympanoplasty type III, in 10 (67%) of 15 ears with tympanoplasty type IV. Tympanoplasty type I and III showed excellent success.
The purpose of this report is to analyze the factors influenced to postoperative hearing result. 103 ears were treated by type III tympanoplasty for five years. We evaluated hearing result by preoperative and perioperative findings. Preoperative findings were used eustachium tube function test and the findings of adhesive tympanie membrane. Perioperative findings were the degree of reservation in epitympanium mucosa and the mobility of stapes footplate. Results were as follows: the degree of mobility of the stapes footplate was observed with significant difference (p<0.01). The other factors were not observed with difference. In conclusion, we should consider the second stage operation for not only cholesteatoma cases but chronic otitis media.
Cartilage has proven to be a reliable material for closure of the tympanic membrane even under difficult conditions. It resists poor trophic conditions, infections and negative pressure. Since introduction in 1970, cartilage palisade technique (CPT) has been increasingly popular in Europe, especially in Germany. In CPT cartilage is applied in many strips, which can avoids postoperative bending and secondary displacement seen with a large cartilage piece. Recent articles reported its high success rate in anatomic and functional results in long term observation. Not any reports on CPT, however, were seen in Japanese literature. In order to determine the morphologic and hearing results of CPT in tympanoplasty, retrospective analysis of 8 tympanoplasties in 6 patients (4 women and 2 men) consecutively operated on from May 2003 to March 2004 was performed. Indications of surgery were large recurrent tympanic membrane perforations due to poor trophic conditions, such as thermal burn, irradiation and tuberculosis, and sequele of middle ear tuberculosis along with adhesive otitis media with cholesteatoma. Otoscopic findings and hearing results using pure tone audiometry were adopted as main outcome measures. The graft take rate was 100%. Postoperative hearing results were improved in six out of 8 ears. Although this report is preliminary, the CPT seems to be suitable to manage difficult pathologic conditions in middle ear surgery. Detailed technique of CPT was also described.
Parental deafness is one of the high risk factors associated with congenital hearing loss in children. Six severe hearing-impaired children who have deaf parents have been followed in our hospital. In this study, we examined these six children when hearing loss was found, when hearing aids were fitted with them and auditory training was started. In addition, we elicited from the six deaf families of how communication was handled at home and in schools, and also their thoughts about cochlear implants. Three cases were referred to our hospital from obstetricians and pediatricians in newborn hearing screening, and their hearing was diagnosed with ABR at one month. Hearing loss in the other three cases was found within one and a half years. Five of the six deaf families in the present study took a great interest in their childrens' hearing, fitting hearing aids and starting auditory training 4-6 months after the diagnosis of hearing loss. The children communicate with their parents through sign language mainly at home and hearing aids are used in schools in four cases. These deaf children came to learn sign language naturally by 2-3 years old. They visit our hospital for consultation regarding handicapped certificate, auditory tests, and to check for aural disease. We are careful about the communication gap when we talk with deaf parents because they communicate with us through sign language interpreters and written Japanese. With regard to cochlear implants, none of the deaf parents wanted their deaf children to have the operation. The deaf parents in our study thought that it is natural to educate their children through sign language and lip reading with hearing aids. As we now have the chance to see these deaf children with deaf parents at an early date after birth, we must try to understand the background of their families as well as support them appropriately.
Pulsatile tinnitus is a rare symptom and is caused by a wide variety of abnormalities. We experienced 3 patients with objective pulsatile tinnitus due to aberrant carotid artery, high jugular bulb or meningoencephalic herniation. They all complained of pulsatile tinnitus and hearing loss and had the tympanic membrane pulsating rhythmically. The radiological studies including computed tomography, magnetic resonance imaging and magnetic resonance angiography were useful in making the diagnosis. Tinnitus disappeared following surgery in patients with aberrant carotide artery and meningoencephalic heriniation and spontaneously without any intervention in a patient with high juglular bulb.
Patients of objective tinnitus are relatively rare. Aneurysms of superficial temporal artery are known as one of origin of objective tinnitus. A 51-year-old woman had an incised wound by windowpane in the front of light ear. The wound was closed by sutures. She was aware of tinnitus immediately after suture. The tinnitus was objectively audible with otoscope. Eighteen days later, she noticed the mass in the left preauricular region. An aneurysm of the superficial temporal artery was detected by MR angiography. The aneurysm was removed by surgery, one year after she had injured. The tinnitus disappeared immediately and did not recur following the treatment.
A 40-year-old male presented with a complaint of unilateral mixed hearing loss after a welding accident, and a middle ear foreign body caused by weldment was diagnosed. Otoscopic findings showed a large eardrum perforation, and moderate mixed hearing loss in the left side was recognized by pure tone audiometry. He complained no vertigo and no disequillibrium sensation. High resolution temporal bone CT scan revealed a 1mm diameter high density material supposedly a metal piece in the tympanic orifice of eustachian tube near the internal carotid artery. Tympanoplasty was performed to remove the foreign body and to close the eardrum perforation under general anesthesia. There were a lmm-2mm width of thin metal piece and a lmm-2mm width carbide piece on mucous membrane in the tympanic orifice of eustachian tube. The rest of the middle ear mucosa, ossicles, round window membrane, chorda tympani and facial nerve were all intact. The foreign bodies were extracted through mesotympanum and tympanoplasty type I was performed with a piece of temporal bone periost into the fibrous annulus. Postoperative high resolution temporal bone CT scan revealed no rest of metal foreign body in the middle ear, and pure tone audiometry showed 10 to 20 dB hearing improvement in low frequencies two month after the surgery. Case of metallic middle ear foreign body is uncommon, but it seems to be necessary that detailed investigation employing high resolution temporal bone CT scan should be conducted in the case of traumatic eardrum perforation due to welding or explosion accident.
A 62-year-old man was refered to our clinic, complaining of the difficulty in removing an ear mold impression. CT examination showed that the impression material impacted tightly into the right middle ear through the perforation of the ear drum. The foreign body was removed piece by piece under general anesthesia by using trans-meatal and trans-tympanic technique. The ear mold impression was used in an eye-glass shop by an inexperienced ear-mold technician who had never examined the ear drum and never used an otoblock before. This accident suggested some important matters as follows. 1. It is not necessary to obtain any license for taking the ear mold impression in Japan. 2. Some of the salesman of hearing aids has poor knowledge of the basic anatomy and physiology of the ear. 3. Before taking impression, no history taking and no examination of the ear were performed occasionally. 4. It is emphasized that the good relationship between experimental ENT doctors and hearing aid dealers should be established.
Varieties of mice- called fancy mice-were kept as household pets in China and Japan from at least the 17th to the early 20th century. They were primarily valued for the varied colors and patterns of their coats. These mice are described in a book entitled Chingan-sodategusa published in Japan in 1787 that included a description of the waltzing mouse, sometimes called the Nankin mouse. As late as the 1850's, the waltzing mouse was considered to be the result of confinement for untold centuries in small cages (Lysenkoism?) but it is now recognized as an inner ear mutant. These mice became objects of scientific inquiry in Europe through W. Haacke's article in A. E. Brehm's 1890 Tierleben, and as a separate communication in 1895. Bernard Rawitz, in 1899, was the first to report the abnormities of the waltzing mouse. They were introduced to North American science by Abbie Lathrop from her farm in Granby, Mass., and became a subject for genetic study through the efforts of William Castle of Harvard. Robert Yerkes, a Harvard graduate student, published his doctoral thesis of 1902, The Dancing Mouse: a Study in Animal behavior, in 1907; this is the first North American monograph detailing and correlating inner ear malformations with behavior. During the first half of the 20th century, many investigators went on to establish the underlying genetics of several of these strains, and used these mutants to characterize pathological anatomy and physiology of genetic deafness. Among the many who have worked productively in this area during the first half of the 20th century are M. S. Deol W. H. Gates, Hans Grüneberg, C. C. Little, and E. M. Lord. These investigators established the foundation for our current use of the mouse as a model for the study of genetic deafness and the normal and abnormal cell and developmental biology of the ear.