The author studied sagittal CT scans of the temporal bone using a method with the head of a patient in sitting position. The sagittal plane is very useful for the visualization of the vertical segment of the facial nerve canal, ossicles, vestibular aqueduct, jugular bulb, and carotid canal. Axial and sagittal CT scans are recommended in patients with cholesteatoma, infranuclear facial paralysis, temporal bone fracture, and diseases involving the vestibular aqueduct, and jugular bulb. But the application of this direct sagittal technique needs further evaluation.
Pre-and postoperative bone conduction (b. c.) thresholds were analysed in 132 ears with chronic otitis media. When the mean value of pre- and postoperative b. c. thresholds was compared, the latter was better than the former, especially in tympanoplasty type I. Significant b. c. improvement was seen for 250 to 2000Hz in tympanoplasty type I, while the postoperative b. c. thresholds were worse at 4000Hz in tympanoplasty type I, and 2000Hz and 4000Hz in modified type III. It was found that the worsening of the postoperative b. c. thresholds was mainly seen in the severe cases, followed by middle or advanced-age cases. On the contrary, improvement of thresholds had a tendency to be seen in the mild cases. The b. c. improvement is possibly due to the impedance change of the middle ear.
The authors report two cases of surgically confirmed attic cholesteatomas in which the processes of formation were revealed by serial CT scan. The first patient, a 11-year-old boy, was referred to our clinic for acute mastoiditis. A CT scan revealed an infected huge cholesteatoma which had deeply invaded the mastoid resulting in extensive destruction of the ossicles. This patient has been followed up after retinoblastoma surgery done shortly after he was born. A CT scan of the orbit performed at the ophthalmological department two years previously was examined, and it revealed that the middle ear had been nearly normal with intact ossicles and aerated attic and mastoid antrum. The cholesteatoma in this case was thought to have developed from a small attic retraction pocket within the previous two years. In the second case, an attic cholesteatoma was found to have developed from a retraction pocket of the pars flaccida during a 10 month follow-up period. Comparison of two CT scans, one before and one after this period, showed the development of erosion of the malleus head and soft tissue density in the attic and antrum.
Bacteria isolated from 29 ears of aural cholesteatoma in children were compared with 111 ears of cholesteatoma in adults in order to investigate the bacteriological features of cholesteatoma in children. Staphylococcus aureus were isolated with higher incidence and Genus Proteus bacilli with lower incidence from cholesteatomas in children than those in adults. Cholesteatoma in children was considered to have lower graded pathology compared to those in adults.
Five cases of congenital meatal stenosis with microtia and retro-auricular abscess due to infection of the associated cholesteatoma were reported. Reviewing the literature, two mechanisms were suggested for cholesteatoma formation in the ears with congenital meatal atresia or stenosis: Development from a nest of epithelial cells entrapped in the atretic or stenotic meatus during the embryonal growth, and insufficient clearance of keratin debris due to failure of the normal migratory pattern of the meatal skin. The latter mechanism seems to be the primary cause for the present cases.
In 7 ears of recurrent adhesive otitis media, their eustachian tube function was examined using tubo-tympanoaerodynamic graphy (TTAG). Using TTAG, the compliant tube can be judged by the findings of contradicting combination of the patent pattern by nasal deep respiration and the stenotic pattern by Valsalva's maneuver. In 4 of 7 ears a typical wave pattern of the compliant tube was detected and 2 ears were also supposed to have the compliant tube because of the findings of the stenotic pattern by Valsalva's maneuver but a good inflation by catheterization. From our study, it is suggested that eustachian tube dysfunction like the compliant tube may play an important role for the etiology of adhesive otitis media and as a cause of recurrence of this disease.
The destruction of the ossicles around the I-S joint in the early pars tensa type cholesteatoma is commonly observed. In this report, we reviewed the clinical data of 9 cases of the early pars tensa type cholesteatoma. Pathological findings confirmed that the destruction of the ossicles around the I-S joint was occurred without active granulation tissue. Moreover, the degree of destruction of the ossicles was related to the length of the duration of the disease and to the extent of the epithelial invasion. Based on these results, destruction of the ossicles around the I-S joint may occur with repetition of slight inflammation without keratine granuloma.
In order to detect several worsening factors in hearing after operation in cases of cholesterin granuloma, 41 surgically treated cases of simple cholesterin granuloma were selected in this study. The following five characteristics were considered to have given the worsening influences to postoperative hearing. 1) Age at tympanoplasty was over 35 years old. 2) The duration of the illness was over 15 years. 3) The case had otorrhea within a month before operation. 4) The case had the perforated ear drum before operation. 5) A large amount of granulation tissues surrounding the ear ossicles was observed during surgery. It is assumed that postoperative hearing should be affected by both the location and volume of granulations directly, and by the duration of the illness, aural discharge and perforation of the tympanic membrane soon before operation, indirectly.
Tha bacterial flora of the nasopharynx was studied in 175 children without recent or present upper respiratory tract infection. Among these children 116 had suffered from secretory otitis media (SOM) of more than three months duration, aged from 2 to 12 years. The remaining cases (59 children) with normal middle ears served as a control. Swab samples were obtained from the nasopharynx via the oral cavity. Pathogens were found in 37 cases (63%) of normal children and 60 cases (52%) of SOM. In the SOM group Streptcoccus pneumoniae and Haemophilus influenzae were isolated in 26 cases (43%) and 16 cases (27%), respectively. The isolation rate of S. pneumoniae was significantly higher in the SOM group than in the control group (p<0.05). Although H. influenzae was more frequently found in the SOM group than in the control group, there was no significant difference between two groups. On the other hand, Staphylococcus aureus and Branhamella catarrhalis were more commonly found in cultures from children with a normal otologic status than in those from children with SOM. Regardless of the presence or absence of the nasal and/or paranasal complications, there was no significant difference in the isolation frequency of micro-organisms among SOM group. The present results supported that S. pneumoniae and H. influenzae in the nasopharynx may play important roles as pathogens of SOM through the eustachian tube.
Sixty ears of 33 children with otitis media with effusion (OME), which had not been improved by conservative treatment, had adenotomy and ventilation tube insertion (VT), were studied. Out of 33 cases, 17 had also tonsillectomy. But there was no significant difference of improvement of OME between cases with or without tonsillectomy. Inprovement of OME was found in cases of 70%. The cases with VT for more than 3 months seemed to have better improvement rate. There were many patients whose VT was removed from March to May showed poor result. It had been reported that many OME cases were suffering from chronic sinusitis or nasal allergy simultaneously. And, in general, these nasal synptoms were more likely aggravated in Spring. As the result, it is concluded that the removal of ventilation tube from March to May was not appropriate for treatment of OME.
This pilot study was made to ascertain the feasibility and the availability of tympanometry in medical examination for three-year-old children to pick up middle ear diseases. Tympanometry was successfully performed in 308 of 315 children (97.8%). Tympanometric test did not interfere with the flow of medical examination, and this trial was cooperatively accepted by the administration as well as by mothers of examinee. Thirty-one children were detected for having tympanometric abnormalities (10.1%), twenty of whom were unilateral and eleven bilateral. We could not find the seasonal alteration of this value. Although the incidence of abnormal tympanograms were lower than expected, we think that introduction of the tympanometry for three-year-old children is useful for turning up the unrecognized middle ear diseases.
Eustachian tube function tests including the sniffing test were performed in a series of 178 ears with middle ear diseases. The sniffing test was positive in 24 ears out of 139 (17%) in pediatric patients and 8 of 39 ears (21%) in adult patients. In the pediatric patients, both the average opening pressure and the closing pressure were significantly lower in the positive sniffing test group than those in the negative sniffing test group. The positive-pressure equalization test and Valsalva test were positive in 92% and 33% of the former group, respectively, while they were positive in 69% and 14% of the latter group, respectively. In contrast, in the adult patients, such difference was not observed irrespective of the results of the sniffing test. Based on these results, the eustachian tubes were assumed to have less resistance to the positive or negative pressure load when the sniffing test is positive compared with those that is negative. Clinical implications of the obtained results were discussed with a literature review.
A 23-year-old man with complaints of hearing loss in the right ear presented with a soft mass found at the lower half of the right ear drum. A pure tone audiogram showed a conductive hearing loss of 30dB. CT scan of the right temporal bonerevealed a soft tissue mass in the hypotympanum. Under general anesthesia, tumor was surgically removed, and neither the auditory ossicles nor Fallopian canal were involved by the tumor. Pathological examination of the mass showed schwannoma, Antoni A type. No facial palsy was noted postoperatively. From these findings, it was concluded that this tumor arose from the tympanic plexus in the middle ear.
A radiolucent shadow on plain X-ray films of the temporal bone was observed in two patients who complained hearing disturbance due to obliteration of the external auditory meatus. In a case of a huge cyst of the mastoid, there were a round translucency on a plain film and a round cavitation with fluid level on a CT film. The cyst was located in the posterior part of the temporal bone and the cyst was suspected to be formed by a blockage of the aditus ad antrum. In the other case, a large giant cell tumor showed a lobulated translucency on a plain film and a large mass with defect of the head of mandible on a CT film. The mass was recognized in the antero-posterior part of the temporal bone, and this tumor was suspected to be originated from the head of mandibule.
A 46 year-old male was first seen with a complaint of a left progressive hearing loss, facial weakness, hoarseness, and swallowing difficulty. Physical and radiological examinations revealed a space occupying lesion involving the petrous part of the temporal bone and infratemporal fossa on the left side. After subtotal removal of the lesion, which was done by the neurosurgeons, a diagnosis of chondrosarcoma invading the left temporal bone with multiple involvement of the lower cranial nerves was made. In the area of head and neck, particulary in the temporal bone, chondrosarcoma is extremely rare. There are only 6 case reports of the tumor in the Japanese literature including our case. Since the tumor occurs infrequently and is usually located in an inaccessible region of the skull, it is usually diagnosed after the tumor reaches considerable size and causes multiple cranial nerve deficits or intracranial complications.
Bloom's syndrome is known to have an increased incidence of malignant neoplasms at an early age. This is the first case of neoplasms in the external auditory meatus and tonsillar fossa associated with Bloom's syndrome. A 33-year-old male was referred to our clinic because of his recurrent episodes of left external otitis since his childhood. He was short of stature and had an erythema of his face. Chromosomal study revealed high frequency sister chromatid exchange (SCE) which was compatible to Bloom's syndrome. Squamous cell carcinoma arose from the left external auditory meatus at the age of 37. Because of poor prognosis of Bloom's syndrome, only radiotherapy was performed. Ten months after the irradiation, right tonsillar squamous cell carcinoma was found. The lymphocytes composed of two populations, one with normal SCE frequency and the other with increased SCE frequency, regardless of autosomal recessive inheritance of this disease.
The therapeutic effect of the high-dose steroids was investigated in 7 cases of sudden deafness with a profound hearing loss and the result was compared with that of 14 cases with a profound hearing loss treated by the ordinary therapeutic protocol. The steroids were administered by the modified Stennert's protocol. There were no clear differences in the outcome of hearing loss between these groups. However, the rapid recovery of the hearing loss was observed immediately after the administration of the high-dose steroids in 2 cases which showed no clear recovery by the prior treatment with Urokinase®. The leucocytosis and elevation of serum GOT and GPT were found in more than half of the cases which could be the side effects of administration of the high-dose steroids and Molecular Dextran L®. However, these side effects disappeared rapidly after the administration was completed.
Five cases of steroid dependent sensorineural hearing loss are reported. These patients consisted of 2 males and 3 females. There were 2 cases of aortitis syndrome in 3 females patients. Three ears of them (5 cases) showed total deafness on their first visit to our clinic. Steroid seemed effective on sensorineural hearing loss except for total deafness. Clinical blood examination revealed an elavation of blood sedimentation rate. The sedimentation rate fluctuated according to the steroid effects for the hearing loss. It is important to determine what kind of steroid is effective and how much dose should be administered to each patient. The blood sedimentation rate was one of the important paramenters to diagnosis and observe effectiveness for the steroid responsive sensorineural hearing loss.
When the facial nerve has been sacrificed and intracranial reconstruction is performed in surgery of acoustic neurinoma, placement and tying of sutures present a difficult technical problem. In order to solve this technical difficulty, we have tried a reconstructive procedure which, by using fiblin glue, required no placement of suture in 3 cases. In one case we performed direct end-to-end anastomosis and in two cases we carried out nerve-grafting. In one case of nerve-grafting which has been followed for 21 months after surgery, facial function began to return 6 months postoperatively and a satisfactory recovery has been obtained. In one case, of end-to-end anastomosis, facial function began to return 8 months after surgery and is still improving 14 months postoperatively. In the remaining one case of nerve-grafting, of which the follow-up period is as short as 7 months, motor unit potentials are recognized electromyographically despite no recovery of the facial function clinically. These results seem to be as good as or better than those obtained after reconstruction by the conventional suture technique. Although more analysis is needed, we have had the impression that this technique using fibrin glue is advantageous over the suture in simplicity as well so that the former can be a substitute to the latter in reconstructing the facial nerve intracranially.
A 6-year-old boy visited our outpatient clinic with the chief complaints of sensation of swelling around neck and sore throat. He had been asymptomatic until 3 days previously when he developed these symptoms after he received tubal catheterization by a local ENT-doctor. He had been treated with Politzer inflation by the same doctor for past 1 year for serous otitis media without any complications. It was the first experience for him that he was treated by tubal catheterization. After the tubal catheterization for the following 2 days, the sensation of swelling around the neck and sore throat were aggravated. Physical and radiological examination disclosed emphysema in the neck and upper mediastinum. Resting on bed and prophylactic administration of antibiotics were started, and emphysema was disappeared within a few days.