Meniere's disease is a common inner ear disease with an incidence of 15-50 per 100, 000 population. Since Meniere's disease is thought to be triggered by an immune insult to inner ear, we examined intra-endolymphatic sac application of large doses of steroids as de novo treatment for intractable Meniere's disease. METHODS Between 1996 and 2005, we enrolled and assigned 197 intractable Meniere's patients to three groups: Group-I (G-I)-patients who underwent endolymphatic sac drainage and steroid-instillation, Group-II (G-II)-those who underwent endolymphatic sac drainage without steroid-instillation and Group-III (G-III)-those who declined endolymphatic sac drainage. Definitive spells and hearing in all three groups were determined for 2-7 years after treatment. RESULTS According to the criteria in 1995 AAO-HNS, two-year results demonstrated that vertigo was completely controlled in 88.0% of patients in G-I (n=100), 85.1% in G-II (n=47) and 8.0% in G-III (n=50)(statistically G-I=GII>G-III). Hearing was improved in 49.0% of patients in G-I, 31.9% in G-II and 6.0% in G-III (statistically GI>G-II>G-III). Results after seven years showed that vertigo was completely controlled in 78.8% of patients in G-I, 79.2% in G-II and 25.0% in G-III (statistically G-I=G-II>G-III). Hearing improved in 36.5% of patients in GI, 8.3% in G-II and 0.0% in G-III (statistically G-I>G-II=G-III). DISCUSSION From non-surgical observation in G-III for at least 7 years after treatment, large doses of steroids instilled into endolymphatic sac in G-I significantly improved hearing in intractable Meniere's patients, more so than endolymphatic sac drainage without steroids in G-II.
This retrospective study included 18 children with congenital inner ear malformations received cochlear implantation. Nine cases had classical Mondini anomalies, 4 large vestibular aqueduct syndrome, 3 semicircular canal aplasia and the remaining 2 inner auditory canal anomaly and cochlear hypoplasia. The congenital inner ear malformations consisted 17% in all 108 children receiving cochlear implants. Fifteen cases underwent cochlear implantation with posterior tympanotomy via mastoid cavity. On the other hand, 3 cases with middle ear malformations, including hypoplasia of the mastoid cavity, required trans-external auditory canal approach, and one of them showed an abnormal route of the facial nerve. Although cerebrospinal fluid leakage was encountered during cochleostomy in 4 cases, none of them required middle ear cavity obliteration or spinal drainage. Seven cases, including Mondini anomaly, semicircular canal dysplasia and cochlear hypoplasia, showed no electrically evoked compound action potential in intra-operative neural response telemetry (NRT) measurements. Speech recognition tests at 2 years after implantation showed good results except for 2 children with semicircular canal aplasia and one of the Mondini anomaly cases.
Among patients with severe acute otitis media under 3 years of age who visited my clinic between January 2006 and December 2007, amoxicillin (70mg/kg/day)/clavulanic acid (5mg/kg/day)(AMPC/CVA (14: 1)) was administered for 7 days to 105 patients in whom either S. pneumoniae, S. pyogenes, M. catarrhalis, or H. influenzae was detected from the nasopharynx. Changes in bacteria detected in the nasopharynx before and after administration were investigated, and the following results were obtained: 1. Bacteria detected before administration were 42 strains of S. pneumoniae (23 strains of drug resistant S. pneumoniae)(27%), 4 strains of S. pyogenes (3%), 14 strains of M. catarrhalis (9%), and 95 strains of H influenzae (70 strains of ampicillin (ABPC)-resistant H influenzae)(61%); and the disappearance rates of bacteria were 88% in S. pneumoniae, 100% in S. pyogenes, 100% in M. catarrhalis, and 52% in H influenzae, showing significantly higher disappearance rates of S. pneumoniae and M. catarrhalis than H. influenzae. 2. Of 57 strains of bacteria detected after administration, there were 47 strains of H influenzae detected at a high rate (82%), among which 38 strains were ABPC-resistant H influenzae. 3. The detection rate of β-lactamase-producing H influenzae increased significantly from 7 of 95 strains (7%) before administration, to 10 of 47 strains (21%) after administration. 4. After administration of AMPC/CVA (14: 1), it should be paid attention to remnants of ABPC-resistant H.influenzae such as β-lactamase-producing bacteria. 5. When patients treated with AMPC and patients treated with AMPC/CVA (14: 1) were compared, the disappearance rates of S pneumoniae, M. catarrhalis, and H. influenzae were all higher in patients treated with AMPC/CVA (14: 1), with significant differences in M. catarrhalis, H. influenzae, and β-lactamase non-producing ABPC sensitive H. influenzae. It was shown that AMPC/CVA (14: 1) might be more effective than AMPC for the removal of bacteria from the nasopharynx.
In conformation of guidelines in treatment of acute otitis media in children in Japan, we reviewed 792 cases of children with acute otitis media treated in our hospital, we obtained the following results: 1) According to this classification, 68 cases were mild, 584 cases were moderate, and 140 cases were severe. 2) According to the treatment algorithm, the percentage of cases improving with primary treatment, second treatment and third treatment was 78.5%, 92.1%, 100% in mild cases, 62.4%, 94.7%, 100% in moderate cases, and 79.4%, 94.1%, 100% in severe cases, respectively. 3) The cases requiring third treatment in mild cases showed a high score of bulging of the tympanic membrane, and in moderate cases, a high score of the tympanic membrane and no tympanotomy, and in severe cases, age under 2 years old and insufficient diminition of otorrhea even with tympanotomy. 4) All mild cases were completely cured, whereas moderate cases showed complete cure in 89.0%, flareup in 7.7%, and recurrence in 9.3%, and severe cases showed complete cure in 85.0%, flare-up in 5.7%, and recurrence in 9.3%. However, in severe cases, 11 patients underwent a short-term ventilation tube insertion. 5) According the guidelines in management of acute otitis media in children it was shown the improvement of more than 90% after second treatment and the cure in more than 85.0%.From these results, we considered that this guidelines are effective for treatment of otitis media in childhood.
We evaluated the postoperative hearing results of 209 cases who underwent tympanoplasty type IV between January 1990 and June 2006 in our department. Using the postoperative hearing result assessment criteria according to the Japan Society of Otology in 2000, hearing was evaluated in at least 6 months after surgery. In the case of non-inflammatory disease such as ossicular chain dislocation or middle ear abnormality, successful hearing results were obtained in 90% of the patients who underwent tympanoplasty type IV-i, while the same successful results were obtained in 89.7% in type IV-c. In the case of congenital cholesteatoma, successful hearing results were obtained in 75% in type IV-i and 72.4% in type IV-c. In the case of acquired cholesteatoma, successful hearing results were obtained in 44.4% in type IV-i and 34.4% in type IV-c. The successful hearing results of tympanoplasty type IV-i was superior to that of type N-c in each group. When the postoperative hearing results were analyzed according to the type of materials for ossiculoplasty, there was no significant difference between homograft cartilage, homograft bone, and artificial allograft prostheses. These findings indicated that tympanoplasty type IV-i was considered to be selected in the case of inflammatory disease, if they were available due to the condition of diseases.
The same-day bilateral tympanoplasty has not been widely accepted because of the theoretical risk of iatrogenic sensorinerural hearing loss in most surgeons. But it would be of benefit physically, economically and time-saving to the patients. We evaluated the results of the same-day bilateral tympanoplasty performed between April 2001 and September 2007. 19 patients (28 ears) underwent the surgery, 9 males and 10 females, aging 14-73 (3teenagers, 10 over sixty years of age). There were 15 patients (30 ears) with bilateral chronic otitis media, 2 patients (4 ears) with bilateral cholesteatoma, 2 patients (4 ears) with postoperative chronic otitis media. The closure of the ear drum perforation was successful in all of 28 ears (100%). According to the criteria of Otology Japan (2000), successful postoperative hearing improvement was achieved in 25 ears of all 27 ears (93%) in chronic otitis media, in all of 3 ears (100%) in cholesteatoma and in all of 3 ears (100%) in postoperative chronic otitis media. None of their hearing level deteriorated comparing their preoperative hearing level. In tympanoplsasty type I, the success rate was 95%(20/21) and in type III, the success rate was 80%(4/5). We concluded that the same-day tympanoplasty can be performed under the condition with a sufficient informed consent to patient and by experienced surgeons.
Although most of acquired middle ear cholesteatomas are considered to be formed by retraction of the tympanic membrane (TM), there are some cases in which the TM epidermis extends into the medial surface of the TM from the margin of its perforation, namely so-called secondary cholesteatoma. This type of cholesteatoma was found in 14 of 460 ears (3.0%) with acquired middle ear cholesteatoma operated on in our hospital from 1992 to 2007. An irregular margin of the perforation was found in 9 of 14 ears. The epidermis was found to be extended into the medial surface of the TM at the perforation edge adjacent to the malleus manubrium in all the cases. We classified them into three types, mesotympanic (MT) type (5ears) in which cholesteatoma matrix was localized within the mesotympanum, protympanum (PT) type (4ears) in which cholesteatoma extended into the eustachiantube and the spratubal recess, and retrotympanic (RT) type (5ears) in which choleateatoma extended towards the incudostapedial joint and the retrotympanic cavity. Although cholesteatoma matrix could be removed without mastoidectomy in the MT-type, the PT-type in which cholesteatoma matrix located anterior to the malleus-head or supratubal recess, often required mastoidectomy with anterior tympanotomy. The RT-type tended to have a great air-bone gap due to destruction of the incudostapedial joint by the cholesteatoma extention along the long process of incus.
There have been few reports on Obliterative otosclerosis in Japan, in which the footplate is thickened, the oval window niche is filled-in in varying degrees. A drill-out procedure is usually required to perform a stapes surgery. Computed tomography (CT) of the temporal bone is useful as a preoperative evaluation of obliterative otosclerosis in some cases. But, in others, preoperative diagnosis is difficult, and the thickened footplate is identified only at surgery. In the present study, 7 ears of obliterative otosclerosis of 5 patients were reported. The preoperative CT detected the thickened footplates in 6 ears of 4 patients (85.7%). Stapedotomy with the Skeeter drill was successfully performed in all cases, with an improvement more than 15dB in air conduction and preserved bone conduction threshold. Cases that have air-bone gap with bone-conduction threshold elevation at 4kHz, early onset of hearing loss and rapid progression may be related to obliterative otosclerosis.
Vogt-Koyanagi-Harada disease (VKH disease) has been described in an autoimmune disease that targets melanocytes. Although VKH disease patients were often complaining of tinnitus and hearing loss, small number of the study have been reported about their hearing function. We have investigated the hearing level of 55 patients to obtain the accurate information of their hearing abilities. Almost half of the patients were diagnosed to have a sensory neural hearing loss. In general, the hearing loss in VKH disease has been known to have a good prognosis. When their hearing loss was usually mild and occurred bilaterally, it is difficult to differenciate their hearing loss from the aging. Every patient with VKH disease should be carefully observed in not only their visual function but also their hearing.
We are utilizing the minimally invasive coin hole retrosigmoid approach (RSA) for treatment of vestibular schwannoma with special multiple cranial nerve monitoring as well as the endoscopic “dead-angle” visualization. Our approach showed a unique shape of the craniotomy. At the craniotomy, a 2 Euro coin-size burr hole was drilled and expand it toward the lower cranial nerves, so the all monitoring electrodes on both the facial nerve and the cochlear nerve could be observed safely and surely. The craniotomy shape appeared as of a tear drop, so our technique was named as “Tear drop Euro coin hole technique”. In the preservation rate of the facial nerve function, which was 100% even immediately after the operations, the significant difference was not found between the extended RSA and the coin hole RSA. Whereas the result of hearing preservation was different. Hearing preservation rate was 33% in the coin hole RSA, as about 70% in the rest of entire RSA's. The coin hole RSA was minimally invasive in the aspect of the early recovery from surgery and the applicability to senior patients safely. However, as for the hearing preservation, there were some pitfalls for success. Therefore, we proposed the very careful selection of the approaches depending on the preoperative MRI findings such as the tumor size and the three dimensional pattern and the position of the cochlear nerve associated with tumor mass.
Wegener's granulomatosis (WG) is characterized by granulomatous inflammation involving the upper and lower respiratory tracts and necrotizing vasculitis affecting small to medium-sized vessels. Here, we report the cases of three patients presenting with intractable otitis media with progressive hearing loss as an initial sign. In two patients, a definite diagnosis of WG was made serologically and histopathologically. Although one patient was negative for any test for WG, he was administered predonisolone and cyclophosphamide as a diagnositic medication. All other patients were treated with satisfactory outcomes including hearing improve-ment. In patients with a limited form of WG in the ear and nose who had been previously reported, it iwas difficult to obtain a definite diagnosis by serological or histlogical tests, and a positeve C (PR-3)-ANCA seemed to be a risk facter of poor hearing recovery. However, the hearing could be improved even in patients with a positive C (PR-3)-ANCA if the immunosuppressive medication is administered as quickly as possible. Therefore, precise diagnosis including the diagnositic medication for WG and quick therapeutic intervention are required to interrupt the spread of necrotizing vasculitis to other organs and to improve hearing