Large Bielschowsky head-tilt phenomenon and inconspicuous vertical deviation in the diagnostic positions in congenital superior oblique palsy

PURPOSE

To report a case of congenital superior oblique palsy with an unusually large Bielschowsky head-tilt phenomenon (BHP) and disproportional inconspicuous vertical deviation.

METHODS

Case report.

RESULTS

An 18-year-old woman presented with slight compensatory head tilting and a Bielschowsky head-tilt phenomenon of 50 Delta on left tilting. Magnetic resonance imaging revealed atrophy of the left superior oblique muscle. A Hess screen test showed a slight underaction of the left superior oblique muscle, but neither an obvious overaction of the ipsilateral inferior oblique muscle nor inhibitory palsy of the contralateral superior rectus muscle was found. With a 3-mm recession of the ipsilateral superior rectus muscle, Bielschowsky head-tilt phenomenon decreased to 25 Delta.

CONCLUSION

A large Bielschowsky head-tilt phenomenon was possibly caused by an increased gain of the otolith-ocular reflex affecting the vertical rectus muscle.

Morphological changes in the orbital surface layer muscle of the rabbit eye produced by botulinum toxin

We quantitated the morphological changes in the orbital surface layer muscles in the rabbit following the single injection of botulinum A toxin. Experiments were performed in 9 white rabbits (1.6-3.0 kg). They were administered 5 units (5 rabbits) or 10 units (4 rabbits) of botulinum toxin injected into the superior rectus muscle of one eye. The diameter of myofibers of the orbital and intermediate layer zones was measured with an ocular micrometer on histological sections 3 days and 1, 3 and 5 weeks after injection. Quantitative changes were noted in the muscle fibers of the orbital surface layer zone following the injection of 10 units of botulinum toxin. At 1 week, the diameter of myofibers in the orbital layer was reduced, but it was increased at 5 weeks compared to that in the control eyes; in contrast, no change in the diameter of muscle fibers was found in the intermediate layer zone.

Organic change of effusion in the mastoid in otitis media with effusion and its relation to attic retraction

To try to solve the pathogenesis of severe attic retraction viewed from mastoid condition, we examined the residual soft tissue density (RSTD) in the mastoid by computed tomography (CT) in 85 patients (107 ears) with otitis media with effusion (OME) 3 months after tympanostomy tube insertion or later. The incidence of RSTD in the mastoid was significantly higher in OME of adults (52.6%) than in children (24.1%). Ears with severe attic retraction had RSTD significantly more frequently (80%) than those with no or mild attic retraction, and many of the mastoids with severe attic retraction were occupied totally by RSTD. The area of the mastoid (mastoid pneumatization) was significantly smaller, and CT density of the mastoid (sclerotic tendency) was significantly higher in ears with RSTD than in those without. RSTD after tympanostomy tube insertion in the mastoid indicating organic change of effusion was considered one of the important factors relating to the pathogenesis of severe attic retraction.

Comparative study of brain lesions detected by magnetic resonance imaging between strabismus and nonstrabismus in infancy

PURPOSE

To elucidate the causative factors in infantile esotropia, we evaluated morphological abnormalities in brain structures of esotropia patients showing any abnormal neurological signs in comparison to those of normal controls.

METHODS

Sixty-five developmentally normal children participated in this study. Of these 65, 38 demonstrated infantile esotropia and 27 were normal controls. All underwent magnetic resonance imaging (MRI) of the brain between 2 and 30 months.

RESULTS

Abnormal brain findings were noted in 3 (7. 9%) children in the strabismus group, whereas none of the children in the normal control group showed brain lesions. In these 3 cases, brain lesions involved periventricular leukomalacia, enlargement of the lateral ventricles with hypoplasia of the corpus callosum and myelination delay at the anterior horn adjacent to the lateral ventricles.

CONCLUSIONS

Brain lesions that may disturb normal maturation of the visuomotor system and eventually lead to strabismus could be found in some patients without any episode that would cause birth injury.

Soft-wall reconstruction for cholesteatoma surgery: reappraisal

OBJECTIVE

To reevaluate the validity of the soft-wall reconstruction method of the posterior meatal wall in surgeries for cholesteatomas.

STUDY DESIGN

Retrospective case review.

PATIENTS

Subjects consisted of 52 patients (54 ears) with fresh cholesteatoma (excluding residual or recurrent cholesteatomas) who were operated by the soft-wall reconstruction method in our clinic and observed for more than 2 years after surgery, and 29 patients (29 ears) who were operated by canal-wall-down and open method.

MAIN OUTCOME MEASURES

Postoperative period required for complete epithelization (dry ear), hearing, and incidence of the residual and recurrent cholesteatomas were compared with those operated by canal-wall-down and open method. The postoperative conditions of the soft posterior meatal wall was also investigated.

RESULTS

Postoperative period to be a dry ear was significantly shorter in the soft-wall reconstruction group than in the canal-wall-down and open group (Student's t-test, t = 2.99, p < 0.01). There was no significant difference in the postoperative hearing or incidence of residual and recurrent cholesteatomas between the two groups.

CONCLUSIONS

These results indicate that the soft-wall reconstruction method seems more versatile than the canal-wall-down and open method for cholesteatoma surgery.

Prognostic factors for successful surgical outcome with preoperative prism adaptation test in patients with superior oblique palsy

PURPOSE

This study evaluated the surgical outcome of patients managed with preoperative prism adaptation test (PAT) and investigated prognostic factors for successful motor alignment in adult patients with superior oblique palsy.

METHODS

Prospective study of preoperative PAT was performed. Fifty-seven patients with superior oblique palsy, aged 16 to 81 years, participated in this study. Patients were assigned to surgery with the target angle based on either the original angle or the prism compensated angle. When the amount of neutralizing prism exceeded 4delta or more compared to the original angle of deviation, the patient was defined as having prism compensation, and the target angle for surgery was based on the amount of neutralizing prism. The motor success rate was compared between the 2 groups at the 3-month postoperative follow-up.

RESULTS

The prism responders group showed a superior outcome compared to that of the prism non-responders group (77% successful outcome compared with 46%, p = 0.0397). The presence of prism compensation and the amount of vertical deviation were significant prognostic factors for successful motor alignment.

CONCLUSION

Preoperative PAT is a useful prognostic indicator of successful surgical outcome in patients with superior oblique palsy.

Factors affecting recovery of mastoid aeration after ear surgery

Fifty-six patients after tympanomastoid surgery were examined to determine recovery of mastoid aeration and various pre- and intraoperative factors such as eustachian tube (ET) function, how the mastoid mucosa had been treated during surgery and whether or not a large silastic sheet had been placed in the middle ear or a ventilation tube used. Mastoid aeration recovery was confirmed by computed tomography in 27 of the 57 cases (47%) within 12 months of surgery. Among the factors examined, preservation of the epitympanic mucosa was found to be most important in mastoid aeration recovery. Use of a large silastic sheet to cover the area from the bony ET and tympanic cavity to epitympanum, aditus ad antrum or antrum was found to be of some help in recovery mastoid aeration after complete resection of the mucosa and mastoid air cells. Preoperative ET function, anterior tympanotomy and use of a ventilation tube did not influence recovery.

The diagnostic and prognostic value of eardrum mobility in otitis media with effusion

Diagnostic and prognostic values of eardrum mobility were determined by pneumatic otoscopy in 37 patients (56 ears) having otitis media with effusion (OME). Eardrum mobility was impaired or lost in less than half of the ears (46.4%), while a tympanogram detected 77.8% of OME. In 27 of the 37 patients (42 of the 56 ears), aeration of the middle ear space was examined by CT and demonstrated that the presence or absence of aeration was significantly correlated with the presence or absence of eardrum mobility. In another 38 children (62 ears with OME), effect of antibiotics was correlated with eardrum mobility before treatment, and the improvement rate was found to be significantly higher in ears with positive mobility of eardrum (34.3%) than in ears without eardrum mobility (10.0%). These results indicate that eardrum mobility is a good prognostic indicator of OME rather than its diagnostic indicator alone.

Predicting survival and post-operative complications with Tc-GSA liver scintigraphy in hepatocellular carcinoma

BACKGROUND/AIMS

Technetium-99m galactosyl human serum albumin is a novel liver scintigraphic agent. The aim of the present study was to examine whether liver scintigraphy with this agent could predict changes in hepatic function affecting survival in patients with inoperable hepatocellular carcinoma and liver cirrhosis. We also investigated whether the risk of major complications after hepatectomy for hepatocellular carcinoma could be assessed.

METHODOLOGY

Liver scintigraphy was performed in 42 patients with inoperable hepatocellular carcinoma and cirrhosis and 40 patients undergoing hepatectomy. The ratio of liver to heart plus liver radioactivity 15 min after injection (LHL15) was calculated.

RESULTS

The 1-year survival rates were higher in patients with higher LHL15: 100%, LHL15 > or = 0.91; 77.8%, 0.81 < or = LHL15 < or = 0.90; and 28.6%, LHL15 < or = 0.80. On multifactorial analysis, LHL15 significantly predicted the 1-year mortality rate in the 42 patients (p<0.001). Pre-operative LHL15 was significantly lower in 9 patients with major post-operative complications (0.88+/-0.02) than in 31 patients with uneventful courses or minor post-operative complications (0.93+/-0.01, p<0.001).

CONCLUSIONS

Our results suggest that technetium-99m galactosyl human serum albumin liver scintigraphy is effective for predicting short-term survival in patients with inoperable HCC and cirrhosis and for assessing the risk of major complications after hepatectomy.

Perioperative hepatic functional risk assessed with technetium-99m diethylenetriamine pentaacetic acid-galactosyl human serum albumin liver scintigraphy in patients undergoing pancreaticoduodenectomy complicated by obstructive jaundice

CONCLUSION

Liver scintigraphy with technetium-99m diethylenetriamine pentaacetic acid-galactosyl human serum albumin (Tc-GSA) can be used to predict outcome of biliary drainage and hepatic function after pancreaticoduodenectomy in patients with pancreatic, biliary, and ampullary carcinomas complicated by obstructive jaundice.

BACKGROUND

Preoperative obstructive jaundice has been reported as a crucial risk factor for serious postoperative complications in patients undergoing pancreaticoduodenectomy. The aim of the present study was to investigate whether Tc-GSA liver scintigraphy can assess hepatic functional risk in patients with pancreatic, biliary, and ampullary carcinomas complicated by obstructive jaundice.

METHODS

Liver scintigraphy was performed before biliary drainage in 18 patients with obstructive jaundice. The maximum removal rate of Tc-GSA (GSA-Rmax; standard normal value > or = 0.60) was calculated. These patients underwent pancreaticoduodenectomy with wide lymphadenectomy. The efficacy of preoperative biliary drainage was assessed with the decrease in serum bilirubin concentration in the first week after biliary drainage. Postoperative liver function was assessed with the increase in serum bilirubin concentration, which was the difference between the immediate preoperative and maximal postoperative bilirubin concentrations.

RESULTS

Serum bilirubin decreased more in the first week after biliary drainage in patients with GSA-Rmax > or = 0.60 (7.64 +/- 1.09 mg/Dl/wk) than in patients with GSA-Rmax < 0.60 (3.56 +/- 1.25 mg/DL/wk, p = 0.042). Postoperative bilirubin increased less in patients with GSA-Rmax > or = 0.60 (0.81 +/- 0.30 mg/dL) than in patients with GSA-Rmax < 0.60 (4.00 +/- 0.69 mg/DL, p = 0.0012). Multivariate analysis showed that GSA-Rmax significantly predicted the postoperative bilirubin increase (p = 0.020).

Soft-wall reconstruction of posterior canal wall for surgery of noninflamed ears: a preliminary report

OBJECTIVE

To test whether the posterior external auditory canal (EAC) wall reconstructed only by soft tissues retracts after surgery in the noninflamed ear.

STUDY DESIGN

The condition of the posterior EAC wall was observed for more than 1 year after surgery in 20 noninflamed ears in which only the posterior EAC wall skin was preserved or in which the wall was reconstructed only by soft tissue during surgery.

PATIENTS

Eighteen patients (20 ears) underwent ear surgery for conditions other than otitis media, including ossiculoplasty in 12 ears, cochlear implant in 3, resection of congenital cholesteatoma in 4, and resection of glomus tympanicum tumor in 1.

RESULTS

Retraction of the soft posterior EAC wall was observed in only 1 of the 20 ears. In this ear, the posterior EAC wall showed only a slight retraction without any serious problems. Computed tomography revealed that mastoid aeration recovered in all 20 ears.

CONCLUSIONS

In noninflamed ears, surgeons can remove the bony posterior EAC wall if necessary, and may not need to reinforce or reconstruct the wall with hard tissue. This enables surgeons to spare time and energy and obtain the same advantages as in the intact-canal-wall technique or canal wall reconstruction by a hard material.

[Effect of the skull on brain perfusion SPECT imaging]

Because attenuation gradually decreases reconstructed counts from the periphery to the center portion of the object, the deep region far from the detector is not clearly observed if attenuation is not compensated. In brain perfusion SPECT, diagnosis is sometimes made using filtered back projection images without attenuation compensation (FBP). Brain perfusion SPECT has the unique characteristic that the radiopharmaceutical accumulates only within the brain and is never taken up by the surrounding skull. This study investigated the effect of skull on brain perfusion SPECT reconstructed with FBP. We theoretically derived the relation between the counts of brain and the linear attenuation coefficient of skull. It was found that the difference in reconstructed counts between the deep gray matter and peripheral gray matter decreased due to the existence of the skull. This result indicated that the deep gray matter was inclined to be visible if the FBP images were displayed according to relative counts normalized to the maximum count of each image. In order to confirm this, we made a numerical phantom with realistic human brain and skull contours on the basis of MR images from a normal volunteer. The linear attenuation coefficient of brain was assumed to be 0.15 cm-1, while that of skull was assumed to be 0.26 cm-1 (denoted as BONE+) or 0 cm-1 (BONE-). In accordance with the theoretical results, the deep gray matter of BONE+ images was more clearly observed than that of BONE- images, if these were displayed using the relative counts of each images. The physical phantom experiments also supported the theoretical and numerical phantom studies.

Biometric confirmation of the Hirschberg ratio in strabismic children

PURPOSE

In the Hirschberg eye position test, the ratio of strabismic angle to decentration of the corneal reflex is dependent on two biometric parameters of the eye: the radius of the corneal curvature and the depth of the anterior chamber. This study was designed to confirm whether the Hirschberg conversion ratio (HR) previously determined for adults can be used for children of various ages despite structural growth of the eye.

METHODS

For 262 eyes of 131 children with strabismus (age range, 6 months to 11 years), the radius of the corneal curvature was measured with an auto-keratometer and the anterior chamber depth with an A-scan ultrasound unit under general anesthesia before the surgery. Using these measurements, the HR was computed on the basis of a geometric model.

RESULTS

The calculated HR was constant across the age range, and the mean+/-SD was 19.9+/-1.9 prism diopters/mm (95% confidence interval, 16.1-23.6 prism diopters/mm). The ratios for the two eyes in each subject showed good correlation (R = 0.854, P = 0.0001). Neither of the biometric measurements was significantly correlated with age, although considerable scatter of the measurements was observed.

CONCLUSIONS

These results indicate that the averaged HR can be applied in children regardless of the patient's age, although intersubject variance of the ratio should be taken into account.

[Combined scatter and attenuation correction for 201Tl myocardial perfusion SPECT using OS-EM algorithm]

There are two possible ways to obtain scatter-corrected images with the ML-EM (maximum likelihood expectation maximization) algorithm: one is the subtraction of scatter estimate si from projection data pi, and then (pi-si) is used for scatter-corrected projection data (denoted as SC(T)); the other method is the addition of scatter estimate si to the projections calculated from the reconstructed image without performing data subtraction (SC(E)). This paper investigated these two ML-EM algorithms of combined scatter and attenuation correction on 201Tl myocardial perfusion SPECT imaging. Scatter windows were placed one full width at half maximum (FWHM) below and above the photopeak centerline. The scatter fraction in the primary peak was estimated using trapezoidal approximation by the triple energy window method. Phantom and clinical images were reconstructed using 6 iterations of ordered subsets EM algorithm (OS-EM). A cylindrical phantom with a cold-rod insert and a heart/thorax phantom with liver insert were used to evaluate scatter and the attenuation compensation technique. A cylindrical phantom filled with uniform 201Tl solution was used to evaluate statistical noise. The percent root-mean-square uncertainty (%RMSU) was used as a quantitative measure of noise amplification. %RMSU showed that the SC(E) method amplified noise less in comparison with the SC(T) method, however, no significant difference in image quality was observed between the two methods. In conclusion, both the SC(T) and SC(E) methods provided significant and similar improvement in the removal of scatter in 201Tl myocardial perfusion SPECT imaging.

Characteristics and variability of vertical phoria adaptation in normal adults

We evaluated the characteristics of phoria adaptation for vertically induced retinal disparity. An adaptive change in the fusion-free ocular alignment, phoria adaptation, was measured with a computer-aided mirror haploscope at 10, 30, and 60 minutes after the start of wearing of a 3-prism-diopter base up prism by 35 normal subjects ranging in age from 21 to 67 years (mean: 37 years). The relationships between phoria adaptation and the subjects' age, the vertical fusional amplitude, the amount of heterophoria, and the starting time of the examination were evaluated. All subjects showed phoria adaptation, with the mean (+/- SD) degree of 0.78 +/- 0.28 degree, 0.96 +/- 0.26 degree and 1.02 +/- 0.30 degrees at 10, 30, and 60 minutes, respectively, after wearing the prism. The repeatability (95% confidence interval) for the measurements was less than +/- 0.24 degree. There was a significant correlation between the vertical fusional amplitude and the gain of phoria adaptation (at 10 and 60 minutes, P < 0.05). The gain of phoria adaptation measured at 60 minutes showed a significant decrease with age (P < 0.01). The results indicate that the time course of phoria adaptation in the vertical direction is similar to that in the horizontal direction and its gain differs considerably among subjects.

Influence of the gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases

To investigate the influence of gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases, the authors examined the mastoid pneumatization among patients with sniffing habit using computed tomography, and also examined the change of negative middle ear pressure induced by sniffing using tympanogram. In 20 ears with cholesteatoma or adhesive otitis media, the areas of mastoid cavity measured at the level of the lateral semicircular canal were significantly smaller than those in 26 ears with otitis media with effusion (OME) or attic retraction and in eight normal ears with sniffing habit (P < .01 and P < .0001, respectively). In 26 ears with OME or attic retraction, the areas of mastoid cavity were significantly smaller than those in eight normal ears with sniffing habit (P < .0001). By contrast, in the four ears with sniff-induced middle ear disease, the recovery of negative middle ear pressure in 5 minutes without swallowing was less than 10 mm H2O, whereas in all seven ears with normal eardrum, negative middle ear pressure recovered by more than 20 mm H2O in 5 minutes. These findings suggested that impairment of gas exchange function through the middle ear mucosa, as well as eustachian tube dysfunction, might be closely related to the development of sniff-induced middle ear diseases.

Cause of posterior canal wall retraction after surgery from the viewpoint of mastoid conditions

OBJECTIVE

To determine the relationship between preservation of the mastoid mucosa during ear surgery and retraction of the attic or posterior wall of the external auditory canal (EAC) and mastoid aeration after surgery.

METHODS AND DESIGN

Retraction of the posterior EAC wall and mastoid aeration were evaluated after surgery in 48 individuals (50 ears) with cholesteatoma, adhesive otitis media, or chronic suppurative otitis media, in whom the posterior bony EAC walls were removed with or without preservation of mucosa and reconstructed with soft tissues alone (EAC skin and temporal fascia) during surgery.

RESULTS

Postoperative computed tomography showed that in ears with notable retraction of the posterior EAC wall appearing like an open mastoid cavity, there was no air in the mastoid, whereas in ears with no or only slight retraction there was computed tomographic evidence of mastoid aeration. Second, notable retraction of the posterior EAC wall occurred in a significantly smaller percentage of ears in which at least the epitympanic mucosa had been able to be preserved during surgery than in those that had undergone removal of all mucosa (mastoidectomy).

CONCLUSIONS

These results indicate that 1) preservation of epitympanic mucosa during surgery is an important factor for prevention of retraction of the posterior EAC wall and for reaeration of the mastoid after surgery, and 2) the intact canal wall technique seems to be indicated whenever at least the epitympanic mucosa can be preserved, and when no mucosa can be preserved the canal wall down procedure seems to be indicated.

[Arterial infusion chemotherapy with SMANCS-Lipiodol for multiple hepatocellular carcinoma]

Fifty-five patients with hepatocellular carcinoma were treated with oily anticancer agent SMANCS dissolved in Lipiodol (SMANCS-LPD). The local response rate after the first arterial infusion in all patients was 39%, against 63% in 27 patients with Lipiodol accumulation occupying more than two thirds of tumor areas. The infusion therapy with SMANCS-LPD is adapted for a vascular-rich hepatocellular carcinoma. An infusion of 4 mg of SMANCS was ineffective for patients with tumors distributing in bilateral lobes of liver. Thus, an increase of infusion dosage or repeated infusions were recommended for such cases.

Gas exchange function of the middle ear in patients with otitis media with effusion

Gas exchange function through the middle ear mucosa was assessed using nitrous oxide (N2O) in patients with otitis media with effusion (OME), as well as in normal ears during elective surgery for unrelated disorders. In all normal ears except one (n = 43), an increase in pressure was observed after N2O inhalation. In 42 of 84 ears with OME, a pressure increase was observed, but not in the remaining 42 ears (50%), indicating that the gas exchange function in these latter ears was impaired. In 21 of the 42 ears showing no middle ear pressure increase following N2O inhalation, the middle ear pressure was again monitored after myringotomy and aspiration of the effusion A pressure increase was found in 16 ears, indicating that the impairment in gas exchange function in ears with OME may be reversible in most cases. Computed tomography of the mastoid was examined preoperatively in 66 ears, with the presence or absence of a middle ear pressure change well correlated in 57 ears with the presence or absence of mastoid aeration.

[Preoperative evaluation of the limitation of hepatic resection using 99mTc-GSA (galactosyl human serum albumin) scintigraphy]

Preoperative evaluation of the operative indication of hepatic resection using the parameters obtained by 99mTc-GSA scintigraphy has been done. In particular, the accurate evaluation of the postoperative hepatic functional reserve essentially depends on these parameters. In the present study, a preoperative evaluation of postoperative hepatic functional reserve using 99mTc-GSA scintigraphy was performed in our operated cases retrospectively.

PATIENTS AND METHODS

Thirty-eight patients who underwent hepatic resection were studied on 99mTc-GSA scintigraphy before and after operation. These patients were divided into two groups. Group A; had no postoperative complications (n = 31). Group B; had some postoperative complications (n = 7). Preoperative parameters of 99mTc-GSA liver scintigraphy (HH15, LU15) were calculated from the activities of liver and cardiac ROIs at 5 and 15 minutes after injection. The resection ratio (RR) was obtained by comparing the liver volumes which were calculated from the pre- and postoperative SPECT studies. The resectability indices (Res) were as follows: Res (LU15) = LU15 x (100-RR(%)/100, Res (HH15) = (1/HH15) x (100-RR (%)/100.

RESULTS

There were statistically significant differences in the distribution of Res between A and B groups (p = 0.002, Mann-Whitney test). The values of Res, of which half of patients have complication, were 1.10 (Res (HH15)) and 16.4 (Res (LU15)).

CONCLUSION

The resectability indices using 99mTc-GSA liver scintigraphy are useful for the preoperative evaluation of the limitation of hepatic resection.