The probability of Immunoglobulin A (IgA) nephropathy recurring in a renal graft is approximately 30%. With IgA nephropathy as the primary disease, long-term renal graft prognosis is worse than with non-IgA nephropathy (with the exception of diabetic nephropathy). This “reverse phenomenon” is attributable to the influence of recurrent IgA nephropathy. Whereas one study reported that the prognosis of recurrent IgA nephropathy is often better than that of primary IgA nephropathy, other studies have revealed an unfavorable long-term prognosis or graft dysfunction within short time period. The rate of renal graft loss due to recurrence should be deemed high. After renal transplantation, steroid use is continued to prevent graft rejection; nevertheless, its onset and progression are difficult to prevent completely. The efficacy of tonsillectomy/steroid pulse therapy for recurrent IgA nephropathy in renal grafts has recently attracted attention, and numerous studies have reported generally good therapeutic outcomes. We performed tonsillectomy/steroid pulse therapy for six patients with IgA nephropathy and renal grafts at the division of Otolaryngology, Kochi Health Sciences Center (Kochi, Japan). Long-term follow-up revealed successful suppression of IgA nephropathy in all six cases. The fact that IgA nephropathy can recur in renal grafts suggests an IgA nephropathy etiology other than in the kidney. Considering the efficacy of tonsillectomy/steroid pulse therapy for the treatment of IgA nephropathy, the palatine tonsil is considered a key factor in the onset of IgA nephropathy. In the treatment of recurrent IgA nephropathy in renal grafts, tonsillectomy/steroid pulse therapy should be considered as early as possible as a therapeutic option.
We report herein on an infant with respiratory and feeding disorders due to severe unilateral palatine tonsillar hypertrophy. A female infant at the age of 1.5 month presented with inspiratiory stridor and retractive breathing. Poor weight gain and right palatine tonsillar hypertrophy were noticed in a health examination at the age of three month. The patient was referred to our department at the age of four month, and chronic respiratory and feeding disorders were diagnosed. Tracheostomy was performed at the age of five months, since the respiratory condition had severely deteriorated and the poor body weight gain was persistent. Respiratory symptoms disappeared and weight gain was achieved after the tracheostomy. However, the right palatine tonsillar hypertrophy gradually enlarged and upper airway stenosis developed. The tracheostomy orifice could not be closed. A right palatine tonsillectomy to improve the upper airway and respiratory condition was undertaken at the age of 13 months. The tracheostomy orifice could be closed without any trouble after the tonsillectomy. in infancy, it is rare that tonsillar hypertrophy causes chronic respiratory and feeding disorders. We deliberate the course of the treatment and discuss the case with a review of the literature.
Hypopharyngeal squamous cell carcinomas (HPSCCs) have one of the worst prognoses among malignancies of the head and neck. We applied weekly cisplatin (40 mg/m2) chemoradiotherapy (CRT) for patients with HPSCCs. Induction chemotherapy comprising docetaxel 75mg/m2 day1, cisplatin 75mg/m2 day1, and 5-FU 750mg/m2 day1-5 was used with the aim of preventing distant metastasis. We treated 40 patients with HPSCCs. Of these, 35 patients (87.5%) completed more than five cycles of a weekly cisplatin dose. Ten patients were treated by induction chemotherapy followed by weekly cisplatin CRT. Of these, 9 patients (90%) completed more than five cycles of a weekly cisplatin dose. The 5-year overall survival rate and larynx preserving survival rate in all 40 patients were 73.7% and 66%, respectively. In 10 patients treated with induction chemotherapy, each of the 3-year overall survival rate and the larynx preserving survival rate was 58.3%. It was considered that weekly cisplatin CRT with and without induction chemotherapy was very effective for patients with HPSCCs. It is possible that the weekly cisplatin CRT is suitable as the CRT regimen following induction chemotherapy.
A 44-year-old man underwent tonsillectomy for chronic tonsillitis. Postoperative hemorrhage was observed on the 8th postoperative day and required a hemostatic technique under general anesthesia. The bleeding was originating from the right inferior pole of the tonsillar fossa, and stitches of pharyngeal mucosa around the area were made. Recurrent hemorrhage was occurred on the 5th re-operative day. Observation under a distending videolaryngoscope confirmed the hemorrhage as originating from the dorsal lingual artery. A titanium hemo-clip was applied to ligate the artery. The patient was discharged on the 16th postoperative day (29 days after the tonsillectomy) with no further recurrent hemorrhage.
Post-operative hemorrhage following tonsillectomy is a troublesome complication. It can be classified as early hemorrhage or late hemorrhage. The authors of this study retrospectively compared 59 harmonic scalpel tonsillectomies with 54 electrocautery tonsillectomies in terms of post-operative hemorrhage. Early hemorrhage occurred less when using the harmonic scalpel, and late hemorrhage was equivalent when using the harmonic scalpel or electrocautery.
Salivary duct carcinomas (SDCs) is a malignant salivary gland tumor with relatively rare and high grade malignancy. We treated seven SDC patients in our department in the period from 2006 to 2015 and retrospectively investigated the results of fine-needle aspiration cytology (FNA) and the relationships between pathological and immunohistochemical findings and the prognosis in SDC. The subjects were six males and one female and the average age of the patients was 64 years (range: 59-73 years). Six tumors occurred in the parotid gland and one in the submandibular gland. In 4 patients local recurrence or metastasis occurred, and three of them died. In preoperative FNA, six cases of seven SDC patients were Class V and only one case had been diagnosed as having SDC. For the immunohistochemistly findings, the positive rate of androgen receptor (AR), human epidermal growth factor type-2 (HER-2) and epidermal growth factor receptor (EGFR) were 86%, 57% and 71%, respectively. Furthermore, the average value of the MIB-1 labeling index was 31.8%. FNA is a useful examination to determine the malignancy in cases of SDC. In all cases that resulted in a local recurrence or distant metastasis, the common findings were vascular and/or perineural invasion. This finding is likely to be a prognostic factor.
IgA nephropathy is sometimes recurrent after kidney transplantation, and the recurrence rate is about 40% within 6-8 years. Furthermore, as failure of the transplanted kidney sometimes occurs because of recurrence, this may be a problem related to lower graft survival associated with IgA nephropathy. However, the effectiveness of a tonsillectomy and steroid pulse therapy has been suggested for the recurrent IgA nephropathy after a kidney transplant. In our hospital, for the purposes of relapse prevention, we performed prophylactic tonsillectomies for IgA nephropathy patients with kidney transplantation who had not previously undergone a tonsillectomy. In the 39 patients followed for up to five years, we observed no clinical and pathological signs of recurrence in any of the cases so far. Postoperative bleeding, infection and complications after surgery were showed no significant difference compared with normal tonsillectomy.
Tonsillar metastasis from lung cancer is uncommon. We report herein on a case of small cell lung cancer found by tonsillar metastasis. A-67-year-old man complaining of an abnormal sensation of his throat and dyspnea was referred to our hospital. Physical examination revealed that a right palatine tonsil was swollen, the surface of which was rough, but which had good mobility. A biopsy of the tonsillar tumor and immunohistological analysis led to a histological diagnosis of small cell carcinoma. CT scan showed the enlargement of a right cervical lymph node and a mass in the left lower lobe of the lung. Small cell carcinoma of the lung was diagnosed following a transbronchial biopsy. Because of metastasis to the tonsil, we diagnosed the primary as T2N0M1b, Stage IV lung cancer. The patient underwent intravenous chemotherapy, and the tumor lesions in the tonsil, neck, and lung reduced subsequently in size for a while, but still remained. We performed a right tonsillectomy and right neck dissection. After the surgery, there was no recurrence in the head and neck lesion. Fifteen months after diagnosis of tonsillar metastasis, the patient is still alive, and the lung tumor has been treated with chemotherapy. In cases of tonsillar metastasis, it is often difficult to treat the primary lesion. However, surgery for the metastasis lesions may be effective to prevent symptoms such as pain, bleeding and dyspnea.
The American Academy of Sleep Medicine (AASM) published The International Classification of Sleep Disorder, 3rd edition (ICSD-3) in 2014, and the changed criteria for diagnosis of obstructive sleep apnea (OSA) has changed. The major points of modification are that out of center testing (OCST) can diagnose OSA as an equivalent standard to polysomnography (PSG) and OSA is diagnosed even if the apnea-hypopnea index (AHI) is five or more and asymptomatic when certain comorbidities (hypertension, type 2 diabetes mellitus, etc.) are present. We retrospectively investigated the data of PSG and OCST that had been performed before, and considered the effect of the new criteria. Therefore, our own guidelines based on our circumstances to choose the most appropriate diagnostic device are needed immediately.
Behçet's disease is an immune-mediated inflammatory disease with prominent symptoms, including recurrent oral aphthous ulcerations, cutaneous and ocular manifestation, and pudendal ulcers. Special lesions include intestinal Behçet's disease, vasculo-Behçet's disease, and neuro-Behçet's disease, and these manifestations aid in defining the patient's prognosis. In this study, we report on two patients with suspected intestinal Behçet's disease. They presented with multiple aphthous and laryngopharyngeal ulcerations, persistent fever, and pharyngeal pain did not respond to antimicrobial and antiviral agents. Intestinal ulcerations were observed on colonofiberscopy, and Behçet's disease was suspected. In general, for patients with refractory laryngopharyngeal ulcers both gastrofiberscopy and colonofiberscopy should be considered, even in the absence of abdominal symptoms.
The current gold standard for the diagnosis of obstructive sleep apnea syndrome (OSAS) is a nocturnal in-laboratory polysomnography (PSG) study. However, PSG uses many sensors and is frequently difficult to perform for children. We studied 26 children between the age of 3 and 14 years, who were suspected of having OSAS, using the integrated PSG system with a simple, portable EEG sleep monitor, Sleep ProfilerTM. With several children, we experienced failures of mounting the EEG or flow sensors because of the difficulty in monitoring the sensors in real time. The arousal index in children with moderate to severe OSAS was higher than that in children with mild OSAS; however, there was no difference in the sleep stage. In one case with Down syndrome, where the results of the portable monitoring device were inaccurate because of frequent midway awakening, continuous positive airway pressure (CPAP) therapy could still be administered to the patient based on the results from the integrated PSG system. The integrated PSG system is useful for diagnosing pediatric OSAS in hospitals without conventional PSG systems.
Retropharyngeal abscess (RPA) is an acute deep space neck bacterial infection, whereas Kawasaki disease (KD) is an acute multisystemic vasculitis of unknown etiology in younger children. There have been several reports about patients with KD accompanying retropharyngeal edema that can mimic RPA. We report herein on two cases of RPA and KD presenting with similar symptoms and observations. The case of RPA was a 3-year-old boy with fever, sore throat and cervical swelling. Computed tomography (CT) revealed a retropharyngeal low density area with a ring enhancement. The treatment with antibiotics and surgical drainage was very effective. The case of KD was a 5-year-old boy with fever, sore throat and cervical swelling. CT revealed a retropharyngeal swelling with a partial low density area which did not show any ring enhancement. Based on the diagnosis of retropharyngeal cellulitis, treatment with antibiotics was administrated but failed to lead to an improvement. After 5 days of treatment, bilateral conjunctival congestion and changes in the oral mucous membranes appeared. The echocardiogram showed no coronary artery abnormality, resulting in the diagnosis of incomplete KD. Administration of intravenous immunoglobulin with high-dose aspirin led to an immediate lowering of the fever and recovery of the patient's general condition. KD with retropharyngeal edema is a rare complication, and it is not easy to distinguish KD with retropharyngeal edema from a bacterial deep space neck infection during the early phase of the disease. Our cases suggest that a ring enhancement in neck CT imaging may be useful to distinguish between these two diseases during the early phase.
Epstein-Barr virus (EBV) positive diffuse large B-cell lymphoma (DLBCL) of the elderly is a provisional entity in the 2008 WHO classification system and is defined as an EBV-positive monoclonal large B-cell proliferation that occurs in patients >50 years of age and in whom there is no known immunodeficiency or history of lymphoma. We experienced the case of an EBV-positive DLBCL of the elderly which emerged with a rapidly expanding pharyngeal ulcer. A 57-years-old man with sore throat, nasal congestion and purulent nasal discharge was admitted to our hospital. Swelling and ulceration of the nasopharyngeal mucosa were observed in endoscopy and computed tomography. Positron emission tomography showed the accumulation of fluorodeoxyglucose in the nasopharyngeal and oropharyngeal mucosa. The biopsy of the nasopharyngeal mucosa only showed inflammation and necrosis despite the progression of the lesion. The second biopsy showed an increase in giant lymphocytes with atypia which were positive for CD20 on immunohistochemistry and EBER on in situ hybridization, resulting in the diagnosis of EBV-positive DLBCL of the elderly. Despite treatment with systemic chemotherapy, the patient died from multiple organ failure. There have been few reports about patients with EBV-positive DLBCL of the elderly which emerged with a pharyngeal lesion; however, it is thought that patients with this disease will increase in the near future due to the ageing population. The awareness of otolaryngologists to this disease is thought to be important for early diagnosis and treatment.
Necrotizing soft tissue infections (NSTI) are defined as infections of any of the layers within the soft tissue compartment consisting of the dermis, subcutaneous tissue, fascia, or muscle that are associated with rapid spread of necrotizing changes. NSTI are life-threatening medical emergencies that require early aggressive treatment such as surgical debridement and adequate antimicrobial use to improve survival rates. Herein, we present a case of a 57-year-old woman who acquired cervical necrotizing soft tissue infection with concomitant untreated diabetes mellitus. A surgical debridement was carried out on the very day of her emergency room visit and a broad skin defect was left in her right neck as a consequence of widespread infection. Negative pressure wound therapy (NPWT) was therefore applied on the 48th day and skin grafting was performed on the 70th day leading to wound closure. NPWT is a therapeutic technique using a sealed wound dressing connected to a vacuum to promote healing in intractable wounds. The introduction of NPWT appeared to be of great utility for decreasing the skin defect.
Although psychogenic taste disturbance is a symptom of a depressed state, no diagnostic criteria for the condition have been established. The present study involved 298 patients (74 males, 224 females; mean age: 60.1 years) with psychogenic taste disturbance and 416 patients (186 males, 230 females; mean age: 59.3 years) with idiopathic or zinc deficiency-related taste disturbance (control group). Questionnaires about symptoms, disease duration, the degree of depression (based on the self-rating depression scale [SDS]), and symptom severity (based on visual analog scales) were performed. In addition, taste functions were assessed using electrogustometry (EGM) and filter paper discs, and saliva quantity was also measured. The patients with psychogenic taste disturbance (11.3 months) demonstrated a significantly longer mean disease duration than the control group (9.2 months). Although the psychogenic group included significantly more females than the control group, the ages of the 2 groups did not differ significantly. Of the psychogenic patients, 36.1%, 34.9%, and 33.4% complained of allotriophagy, glossalgia, and xerostomia, respectively. These rates were significantly higher than those seen in the control group. The psychogenic patients exhibited significantly lower EGM thresholds than the control group (p<0.001). In addition, resting saliva quantity and stimulated saliva quantity were 67.8% and 34.0% lower, respectively, in the psychogenic group (p<0.001). These findings indicated that the regulation of the autonomic nervous system had deteriorated in the psychogenic patients. The SDS scores of the psychogenic patients were normal in 11.6% cases and indicative of neurosis and a depressed state in 53.9% and 34.5% of cases, respectively. These figures differed significantly between the 2 groups (p<0.001). Taste-related symptoms improved more slowly in the psychogenic group than in the control group. It is suggested that the tests and questionnaires employed in this study facilitate the diagnosis of psychogenic taste disturbance.
Actinomycosis is a inflammatory disease mainly caused by Actinomyces israelii. The cases have decreased with the development of antibiotics. However, even now, we sometimes come across it. Most of them are caused by dental diseases, and immune-compromised patients have a higher risk of developing actinomycosis. We experienced two patients with cervicofacial actinomycosis, who were taking immunosuppressants following kidney transplantation, and had dental diseases. Histopathological diagnosis was helpful for adefinitive diagnosis, and administration of high doses of AMPC for a long time was effective. Otolaryngologists should consider this unusual disease as a differential diagnosis for a cervicofacial abscess or tumor.
Sleep apnea syndrome (SAS) is a common disorder. In the case of suspected SAS, the general treatments have included the doctor's interview, a screening test with a portable device and overnight polysomnography (PSG) as necessary. In Japan, in terms of implementation and adaptation of continuous positive airway pressure (CPAP), the apnea hypopnea index (AHI)≧40 was calculated using portable monitoring, and an AHI≧20 using PSG. However, portable monitoring cannot detect other sleep disorders which exist with SAS. It is preferable to have PSG which includes brain wave, electromyogram and electrooculogram findings. In this study, we identified a case of epileptic wave associated with SAS by means of PSG. In addition to SAS, an electroencephalographic abnormality was observed on PSG after portable monitoring, and electroencephalography diagnosed idiopathic generalized epilepsy. Therefore, it should be borne in mind that there is possibility of other sleep disorders occurring concomitantly with SAS.
We report herein on a patient who suffered from Henoch-Schönlein purpura-associated repeated hemorrhage after tonsillectomy. The patient was a 29-year-old man, with reccurent primary and secondary hemorrhage for 7 times after tonsillectomy. We performed ligation to improve the hemorrhage under general anesthesia instances and in the other instances the hemorrhage stopped spontaneously in less than 3 hours. All hemorrhage were from veins not aortic and the bleeding period and condition differed from normal hemorrhage after tonsillectomy. Because a renal biopsy showed the crescent formation, we think the high activity of the vasculitis due to Henoch-Schönlein purpura was the strong reason for the hemorrhage. The reccurent hemorrhage improved after initiation of a steroid pulse therapy.
Objective: The aim of the present study was to investigate the degree of choanal coverage by adenoids and the prevalence of adenoid tissue intruding into the nasal cavity (AINC) in pediatric patients with sleep-disordered breathing (SDB) and identify factors associated with these two findings. Methods: One hundred and sixty-nine patients (118 males and 51 females) undergoing initial adenoidectomy for SDB were enrolled. In each patient, the degree of adenoidal choanal coverage was estimated intraoperatively based on the levels of the choanal structures hidden by the hypertrophic adenoids, and the existence of AINC was determined during powered adenoidectomy. The associations between the presence of severe choanal coverage/AINC and various etiological factors including gender, age, underlying nasal diseases, preoperative apnea hypopnea index (AHI) and combined surgical procedures were retrospectively assessed. Results: The patients whose adenoids hid the inferior turbinate displayed a significantly lower prevalence of AINC. In addition, the patients diagnosed as having allergic rhinitis (AR) showed a significantly higher AINC prevalence than those without AR. In contrast, the group of patients diagnosed as having bacterial rhinosinusitis (BRS) showed a higher number of adenoids hiding the inferior turbinate than those without BRS. Conclusions: The present results demonstrated that in pediatric SDB patients, the prevalence of AINC is negatively versus positively associated with severe choanal coverage by adenoids and AR, respectively, suggesting the existence of preferential directions for adenoid growth.
We report herein on a case of laryngeal papilloma that had invaginated into the esophagus in a 66-year-old male. His tumor was incidentally discovered during a routine gastrointestinal endoscopy. The base of this tumor was located at the right arytenoid region and its head drooped into the esophagus. Although the head moved to epiglottic vallecula as seen on computed tomography, it was not visualized by magnetic resonance imaging due to the invagination of the tumor into the esophagus. It is also difficult to observe the tumor with a fiberoptic endoscope even with the Valsalva maneuver. Consequently, we tried laryngomicrosurgery and were able to remove the entire tumor which was approximately 38mm long. The head of the tumor was spherical in form and 5mm in diameter. While the head was pathologically diagnosed as a papilloma, the neck was composed of normal squamous epithelium. The extended length of the tumor neck was considered due to repeated swallowing.