Microglia Negatively Regulate the Proliferation and Neuronal Differentiation of Neural Stem/Progenitor Cells Isolated from Poststroke Mouse Brains

We previously demonstrated that neural stem/progenitor cells (NSPCs) were induced within and around the ischemic areas in a mouse model of ischemic stroke. These injury/ischemia-induced NSPCs (iNSPCs) differentiated to electrophysiologically functional neurons in vitro, indicating the presence of a self-repair system following injury. However, during the healing process after stroke, ischemic areas were gradually occupied by inflammatory cells, mainly microglial cells/macrophages (MGs/MΦs), and neurogenesis rarely occurred within and around the ischemic areas. Therefore, to achieve neural regeneration by utilizing endogenous iNSPCs, regulation of MGs/MΦs after an ischemic stroke might be necessary. To test this hypothesis, we used iNSPCs isolated from the ischemic areas after a stroke in our mouse model to investigate the role of MGs/MΦs in iNSPC regulation. In coculture experiments, we show that the presence of MGs/MΦs significantly reduces not only the proliferation but also the differentiation of iNSPCs toward neuronal cells, thereby preventing neurogenesis. These effects, however, are mitigated by MG/MΦ depletion using clodronate encapsulated in liposomes. Additionally, gene ontology analysis reveals that proliferation and neuronal differentiation are negatively regulated in iNSPCs cocultured with MGs/MΦs. These results indicate that MGs/MΦs negatively impact neurogenesis via iNSPCs, suggesting that the regulation of MGs/MΦs is essential to achieve iNSPC-based neural regeneration following an ischemic stroke.

Change in chorda tympani nerve function after two-stage tympanoplasty for cholesteatoma

Objectives

Chorda tympani nerve (CTN) function may be damaged more by two-stage than by one-stage surgery for middle ear cholesteatoma. However, few studies have reported the relationship between two-stage cholesteatoma surgery and CTN function. This study aimed to investigate CTN function after two-stage surgery for cholesteatoma.

Methods

In this prospective study, 35 patients underwent two-stage canal wall up tympanoplasty (CWUT). Perioperative CTN function was assessed using questionnaires and electrogustometry (EGM). Participants were categorized into minor, major, and section groups, based on the degree of CTN manipulation during surgery.

Results

In the first-stage surgery, posterior tympanotomy with an intact canal wall reduced the degree of CTN manipulation. The incidence of taste disorder after the first-stage surgery was 71.4%. Postoperative taste disorder and the EGM threshold improved early in the minor manipulation group. In the second-stage surgery, no new CTN damage occurred, even if this surgery involved removal of residual cholesteatoma. The incidence of taste disorder after second-stage surgery was less than that after first-stage surgery, independent of CTN preservation. However, the recovery rate of the EGM threshold after second-stage surgery was significantly lower in the section group than in those with CTN preservation.

Conclusion

CTN function, including symptoms and EGM threshold, can be preserved during two-stage cholesteatoma surgery if care is taken to preserve the CTN in both the first- and second-stage surgeries. A two-stage CWUT, ensuring an intact bony annulus, may be effective to facilitate CTN preservation.

Level of Evidence

2b.

Efficacy and Safety of Polaprezinc (Zinc Compound) on Zinc Deficiency: A Systematic Review and Dose-Response Meta-Analysis of Randomized Clinical Trials Using Individual Patient Data

Zinc intake is recommended for zinc deficiency. In clinical practice, polaprezinc has been used as a zinc replacement therapy for zinc deficiency. However, the efficacy of polaprezinc has not been established. To confirm the efficacy on zinc deficiency of polaprezinc and provide additional information on an appropriate regimen, we conducted a systematic review using individual patient data (IPD). We searched PubMed, the Japanese database Ichushi, and the database owned by the marketing authorization holder of polaprezinc. Randomized placebo-controlled trials that reported the serum zinc concentration were eligible. The mean difference of the change from baseline in serum zinc concentration was estimated using a fixed-effects model. The linear dose-response relationship and the subgroup effects were also assessed. Out of 54 unique randomized clinical trials (RCTs), four studies met the eligibility criteria, and we could access IPD for all of them. All three doses of polaprezinc (75 mg, 150 mg, and 300 mg) and the placebo group were examined. The dose-combined overall polaprezinc increased the change from baseline by a mean of 9.08 µg/dL (95% confidence interval: 5.46, 12.70; heterogeneity: I2 = 0.61%) compared to the placebo. A significant dose-response relationship was confirmed (p < 0.001). Baseline serum zinc concentration was considered an effect modifier in polaprezinc 300 mg. All doses of polaprezinc were tolerable, but a dose-response relationship with adverse events (AEs) was observed in gastrointestinal disorders. The dose of 300 mg may be useful among patients with baseline serum zinc concentration of less than 70 µg/dL, and 150 mg for 70 µg/dL or more.

Initial noun meanings do not differentiate into object categories: An experimental approach to Werner and Kaplan's hypothesis

During the initial stage of language development, nouns corresponding to "object categories" are known to be acquired earlier than other parts of speech, including verbs. However, it is unclear whether the semantic content of words is the same for toddlers who have just begun to learn them and adult speakers. This preliminary study experimentally investigated the theoretical hypothesis of Werner and Kaplan, which posited that the initial meanings of noun-like words do not differentiate into specific categories of objects themselves but rather refer to holistic event categories. Toddlers aged 19-35 months (N = 36) were prompted to select one of two juxtaposed video stimuli (e.g., "putting shoes on" vs. "rubbing two baskets" in the match condition, "putting baskets on" vs. "rubbing shoes" in the mismatch condition) using questions about noun-like words (e.g., "Which is shoes?"). Statistical modeling demonstrated that the meanings of noun-like words for toddlers under 21 months of age or with a vocabulary size of less than 140 words were deeply influenced by conventional actions related to the objects (e.g., "putting shoes on"), whereas they subsequently differentiated into specific object categories (e.g., "shoes" alone), becoming "true nouns." These findings support Werner and Kaplan's hypothesis and provide the first experimental evidence for the theoretical and observational assumptions that early words are not easily classified into parts of speech only by their vocables (e.g., nouns, verbs). We discuss the flexibility of vocable-meaning connections during early language development by proposing the "semantic pluripotency hypothesis."

Nasal Symptom Questionnaire: Our Proposed Scoring System and Prognostic Factors in Chronic Rhinosinusitis

OBJECTIVES

We aimed to verify the usefulness of our proposed nasal symptom questionnaire (NSQ) scoring system and to determine predictors linked to the improvement in nasal symptoms in chronic rhinosinusitis (CRS) patients undergoing endoscopic sinus surgery (ESS).

PATIENTS AND METHODS

Ninety-one CRS patients undergoing ESS and 144 volunteers with results of NSQ available were enrolled. The NSQ consists of 10 items. Receiver-operating-characteristic (ROC) curve, area under the ROC curve (AUC), internal consistency, and test-retest reproducibility of the NSQ were analyzed. The relationship of the NSQ score with the visual analogue scale (VAS) was examined. After classifying into two groups, i.e., (i) "improvement group" and (ii) "no-improvement group," factors linked to the improvement in NSQ after ESS were investigated.

RESULTS

ROC-AUC (0.9318), the Cronbach α coefficient (0.8696), and the test-retest coefficient (0.8131) showed high reliability. NSQ score significantly correlated with VAS in both pre- (p < 0.0001, rs = 0.6007) and postoperative stages (p < 0.0001, rs = 0.5975). The postoperative NSQ scores significantly decreased compared with baseline levels (p < 0.0001). In multivariate analysis, the computed tomography (CT) score by the Lund-Mackay scoring system revealed to be significant (p = 0.0481).

CONCLUSION

Our proposed NSQ scoring system was well verified. The CT score can be helpful for predicting the improvement in nasal symptoms after ESS in CRS patients.

Relationship Between p16 Expression and Prognosis in Patients with Oropharyngeal Cancer Undergoing Surgery

BACKGROUND/AIM

Prognostic impact of p16 expression in patients with oropharyngeal squamous cell carcinoma (OSCC) undergoing surgery is not fully examined. The aim of this study was to clarify these issues.

PATIENTS AND METHODS

Sixty-four OSCC subjects were analyzed. Immuno-histochemical staining of p16, a surrogate marker for human papillomavirus (HPV), was performed histopathologically. Data were retrospectively analyzed according to p16 positivity and factors linked to prognosis were also analyzed.

RESULTS

No significant difference was observed in the prognosis between the p16-positive group (n=28) and the p16-negative group (n=36). In patients undergoing post-operative radiation, the p16-positive group (n=18) had a significantly better prognosis than the p16-negative group (n=6). On multivariate analysis, transoral surgery was a significant predictor of overall survival (p=0.0173).

CONCLUSION

Prognostic impact of p16 can be emphasized in a subgroup of OSCC patients undergoing surgery. Surgery with sufficient surgical margin may be chosen as the first treatment for HPV-negative OSCC in some cases.

Change of somatosensory function of the tongue caused by chorda tympani nerve disorder after stapes surgery

OBJECTIVES

Patients after middle ear surgery often complain of taste disturbance and a lingual numbness. The purpose of this study was to objectively assess changes in the somatosensation of the tongue and taste function in patients undergoing stapes surgery.

STUDY DESIGN

Prospective study.

METHODS

Symptoms of taste disturbance and tongue numbness after surgery were investigated before and after surgery in 41 patients (13 males, 28 females; mean age 41.8 years) who underwent stapes surgery. Twenty-eight patients (9 males, 19 females; mean age 43.1 years) underwent sensory and taste function tests before and after surgery. Sensory function of the tongue was measured at the operated side and the nonoperated side using the 2-point discrimination test and an electrostimulator test. Taste function was assessed with electrogustometry (EGM).

RESULTS

The chorda tympani nerve (CTN) was gently touched or stretched in all patients. Postoperative thresholds on the operated side were significantly higher than preoperative thresholds in all tests in the patients who underwent all three kinds of tests. Tongue somatosensory symptoms improved significantly earlier than the taste disturbance postoperatively, and the sensory thresholds returned to the baseline along with recovery of symptoms.

CONCLUSION

These findings suggest that dysfunction of the CTN occurred following surgery even when the CTN was preserved, and that the sensory nerve threshold of the tongue correlated with the symptom of lingual numbness. The CTN may play a role not only in taste function but also in the somatosensory function of the tongue.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:701-706, 2018.

Surgical results and psychological status in patients with intractable Ménière's disease

OBJECTIVES

Mental disorder is often one of the causes to make treatments for Ménière's disease more difficult. The aim in the present study is to examine ratios of the neurosis and depression in patients with intractable Ménière's disease and also relationships between the ratios and surgical results after endolymphatic sac drainage with large doses of steroids.

METHODS

Between 1998 and 2009, we enrolled 263 intractable Ménière's patients and divided into two groups, 207 in surgical group and 56 in non-surgical group. We used the Cornell Medical Index (CMI) and the Self-rating Depression Scale (SDS) at the diagnosis in our hospital to evaluate their psychological condition before treatments. CMI domains III and IV were defined as neurosis and SDS scores more than 40 as depression as a matter of convenience. Two years as well as seven years after surgery, patients with vertigo zero/month and hearing change>-10dB were evaluated in success group and the others in non-success group.

RESULTS

Neurosis and depression were diagnosed in approximately 40% and 60%, respectively, of intractable Ménière's disease. Our results showed that surgical treatment significantly improved vertigo suppression and hearing gain in patients with no psychological symptoms compared with those exhibiting psychological symptoms both in surgical and non-surgical groups. Furthermore, surgical results in cases with mental disorder were superior to non-surgical results in cases without mental distress.

CONCLUSIONS

All taken together, psychological supports could be necessary for improving results both in the surgical and non-surgical treatments for patients with intractable Ménière's disease. Some cases with intractable Ménière's disease should really require additional surgical treatments even after psychological therapies.

EAONO/JOS Joint Consensus Statements on the Definitions, Classification and Staging of Middle Ear Cholesteatoma

The European Academy of Otology and Neurotology (EAONO) has previously published a consensus document on the definitions and classification of cholesteatoma. It was based on the Delphi consensus methodology involving the broad EAONO membership. At the same time, the Japanese Otological Society (JOS) had been working independently on the "Classification and Staging of Cholesteatoma." EAONO and JOS then decided to collaborate and produce a joint consensus document. The EAONO/JOS joint consensus on "Definitions, Classification and Staging of Middle Ear Cholesteatoma" was formally presented at the 10th International Conference on Cholesteatoma and Ear Surgery in Edinburgh, June 5-8, 2016. The international otology community who attended the consensus session was given the chance to debate and give their support or disapproval. The statements on the "Definitions of Cholesteatoma" received 89% approval. The "Classification of Cholesteatoma" received almost universal approval (98%). The "EAONO/JOS Staging System on Middle Ear Cholesteatoma" had a majority of approval (75%). Some international otologists wanted to see more prognostic factors being incorporated in the staging system. In response to this, the EAONO/JOS steering group plans to set up an "International Otology Outcome Working Group" to work on a minimum common otology data set that the international otology community can use to evaluate their surgical outcome. This will generate a large database and help identify relevant prognostic factors that can be incorporated into the staging system in future revisions.

Mechanism of Immune Complex—Mediated Inner Ear Diseases

Tissues of the stria vascularis of normal rabbits were collected as cochlear antigen and injected into the foot pad of guinea pigs. The mechanism of development of endolymphatic hydrops was studied by the tracer method. Damage to the capillary endothelium and an increase in vascular permeability were found in the stria vascularis. Therefore, we studied patients with a raised level of immunoglobulin (Ig) G—class circulating immune complexes (CICs). Hearing loss was found in 3 of 22 patients with significantly elevated IgG CIC levels (13.6%). The relationship between inner ear disease and the presence of CIC was considered to be very significant. The possible mechanism of CIC-mediated inner ear diseases is discussed.

Staging and classification criteria for middle ear cholesteatoma proposed by the Japan Otological Society

In order to provide a basis for meaningful exchange of information among those treating cholesteatoma, the Committee on Nomenclature of the Japan Otological Society (JOS) was appointed in 2004 to create a cholesteatoma staging system as simple as possible to use in clinical practice in Japan. Following the announcement of preliminary criteria for the staging of pars flaccida (attic) cholesteatoma in 2008, we proposed the 2010 JOS staging system for two major types of retraction pocket cholesteatoma, pars flaccida and pars tensa cholesteatoma. Since then, the JOS staging system has been widely used in clinical studies of cholesteatoma in Japan, allowing standardization in reporting of surgical outcomes based on the respective stages of cholesteatoma. We have recently expanded the range of cholesteatoma by adding cholesteatoma secondary to a tensa perforation and congenital cholesteatoma as the 2015 JOS staging system for middle ear cholesteatoma. Although further revisions may be required for universal acceptance of these criteria, we hope our staging system will open the way for international consensus on staging and classification of middle ear cholesteatoma in the near future.

Clinical Study of 1,515 Patients Presenting with Epistaxis Over the Last 6 Years

AIM

This study reviews our clinical experience of patients with epistaxis and discusses proper management.

PATIENTS AND METHODS

We retrospectively investigated 1,515 patients with epistaxis treated in our department between 2005 and 2010.

RESULTS

Men over 50 years old predominated. More than half of the patients (n = 828) first visited after consultation hours, and 40% (n = 606) were brought by ambulance. The most common underlying diseases were circulatory diseases (69%, n = 1,047). Antithrombotics were being administered to 23% (n = 345). Kiesselbach's plexus was the most commonly observed bleeding site (51%, n = 769). In 20% (n = 297), no bleeding point was confirmed because hemostasis had been achieved on arrival. Anterior packing was the most common primary treatment, followed by electrocauterization. Hospitalization was required in 2% (n = 30). Re-bleeding occurred within 14 days after primary treatment in 14% (n = 206). Surgical treatment was performed for 5% (n = 11).

CONCLUSIONS

Patients showing repeated pulsatile arterial bleeding require hospitalization for surgical therapy, although outpatient therapy is sufficient in most cases. A risk of re-bleeding should be considered if patients show unclarified bleeding points and circulatory diseases.

[A Case of Tongue Carcinoma Resection and Reconstruction with Microsurgical Free Flap during Pregnancy]

Malignant tumors during pregnancy are rarely seen by otolaryngologists, and they cause various problems which require special treatment with careful consideration of both the mother and fetus. Cases of tongue carcinoma resection and reconstruction with a microsurgical free flap during pregnancy have not previously been reported in Japan. We report herein on a case, in which the mother and her child made satisfactory progress after surgery. A-33-year-old female at 25 weeks and 4 days of pregnancy was referred to our department for the treatment of a tumor on the right edge of her tongue. Examinations including biopsy revealed SCC (T2N0M0). We performed an operation to remove the tongue carcinoma with the pull-through method and reconstruct the tongue with an ALT flap at just 28 weeks of pregnancy. The postoperative recovery was favorable, and she gave natural birth to a girl safely at 38 weeks and 6 days of pregnancy. She is currently free of disease and her child is growing normally, at 2 years and 10 months after surgery.

[A Clinical Study of 109 Cases of Glottic Squamous Cell Carcinoma]

A total of 109 patients with glottic squamous cell carcinoma were retrospectively evaluated at Hyogo College of Medicine Hospital between 2003 and 2010; 106 patients were male and 3 patients were female, with a median age of 69 years (range, 51-90 years). According to the 7th edition of the Union for International Cancer Control TNM classification, the clinical TN stages were T1aN0 in 47 cases, T1aN1 in 1 case, T1aN2a in 1 case, T1bN0 in 19 cases, T3N0 in 11 cases, T4aN in 5 cases, and T4aN2b in 1 case. No distant metastasis was observed in any cases at initial treatment. Treatments were radiotherapy alone in 75 cases, concurrent chemo-radiotherapy in 20 cases, supra-cricoid laryngectomy in 1 case, and total laryngectomy in 13 cases. Salvage surgery was performed for 14 patients who had undergone radiotherapy or concurrent chemo-radiotherapy. Salvage surgeries included frontolateral partial laryngectomy in 8 cases, supra-cricoid laryngectomy in 2 cases, and total laryngectomy in 4 cases. The 5-year overall survival rate was 77.6%, and the 5-year disease-specific survival rate was 92.5%. The 5-year laryngeal preservation rate was 82.9%. With regard to T-stages, the laryngeal preservation rates were 100% for T1a, 89.5% for T1b, 91.5% for T2, 18.2% for T3, and 16.7% for T4a.

Clinical Study of Surgical Resection for Pulmonary Metastasis of Head and Neck Cancer

Objectives:

Although chemotherapy is a common treatment for pulmonary metastasis of head and neck cancer, the prognosis is still poor. This study aimed to examine and evaluate the efficacy of surgical resection for pulmonary metastasis of head and neck cancer.

Methods:

A total of 15 patients who had undergone 19 resections were examined at our hospital between 2005 and 2012. The patients were followed up for at least 22 months after the surgery, or until their death, with a median period of 36 months. Among the 15 patients, 11 had squamous cell carcinoma, 3 had adenoid cystic carcinoma, and one had malignant melanoma.

Results:

Of the 19 resections, partial lung resection was performed in 13 cases, lobectomy in 4, and segmentectomy in 2. Video-assisted thoracic surgery was performed in all cases. The mean surgical time, operative blood loss, and length of postoperative hospital stay were 104 minutes, 64 mL, and 7.8 days, respectively. Only 1 patient showed deterioration of the postoperative performance status. For patients with squamous cell carcinoma, the number of pulmonary metastases was 2 or less at the preoperative evaluation. The 3- and 5-year disease-specific survival rates after surgical resection in patients with squamous cell carcinoma were 54.6% and 20.5%, respectively. All patients with adenoid cystic carcinoma and malignant melanoma have survived to date.

Conclusions:

Lung surgical resection can be considered as one of the effective treatments for pulmonary metastasis of head and neck cancer to improve patient prognosis, with minimal invasion and complications.

High fibrinogen in peripheral blood correlates with poorer hearing recovery in idiopathic sudden sensorineural hearing loss

Objectives

We used hearing tests and peripheral blood sample analyses to characterize the pathology of idiopathic sudden sensorineural hearing loss (ISSNHL) and to identify possible prognostic factors for predicting recovery of hearing loss.

Study Design

A retrospective, multicenter trial was conducted.

Methods

Two hundred three patients examined within 7 days after the onset of ISSNHL received prednisone with lipo-prostaglandin E1. Pure-tone auditory tests were performed before and after treatment with these drugs. Blood tests were performed on blood samples collected during the patients’ initial visit to our clinic.

Results

In all patients, elevated white blood cell (WBC) counts, fasting blood sugar levels, HgbA1c, and erythrocyte sedimentation rate (ESR) significantly correlated with high hearing threshold measurements obtained on the initial visit. High fibrinogen levels, WBC counts, ESR, and low concentrations of fibrinogen degradation products (FDP) were associated with lower hearing recovery rates. Additionally, different audiogram shapes correlated with different blood test factors, indicating that different pathologies were involved.

Conclusions

High fibrinogen levels measured within seven days after ISSNHL onset correlated with poorer hearing recovery. This may be a consequence of ischemia or infections in the inner ear. The high WBC counts also observed may therefore reflect an immune response to inner ear damage induced by ischemic changes or infections. Our data indicate that therapeutic strategies should be selected based on the timing of initial treatment relative to ISSNHL onset.

RhoA/ROCK pathway mediates p38 MAPK activation and morphological changes downstream of P2Y12/13 receptors in spinal microglia in neuropathic pain

Recent studies have indicated an important role of ATP receptors in spinal microglia, such as P2Y12 or P2Y13, in the development of chronic pain. However, intracellular signaling cascade of these receptors have not been clearly elucidated. We found that intrathecal injection of 2-(methylthio)adenosine 5'-diphosphate (2Me-SADP) induced mechanical hypersensitivity and p38 mitogen-activated protein kinase (MAPK) phosphorylation in the spinal cord. Intrathecal administration of P2Y12/P2Y13 antagonists and Rho-associated coiled-coil-containing protein kinase (ROCK) inhibitor H1152 suppressed not only p38 MAPK phosphorylation, but also mechanical hypersensitivity induced by 2Me-SADP. In the rat peripheral nerve injury model, intrathecal administration of antagonists for the P2Y12/P2Y13 receptor suppressed activation of p38 MAPK in the spinal cord. In addition, subarachnoidal injection of H1152 also attenuated nerve injury-induced spinal p38 MAPK phosphorylation and neuropathic pain behavior, suggesting an essential role of ROCK in nerve injury-induced p38 MAPK activation. We also found that the antagonists of the P2Y12/P2Y13 receptor and H1152 had inhibitory effects on the morphological changes of microglia such as retraction of processes in both 2Me-SADP and nerve injured rats. In contrast these treatments had no effect on the number of Iba1-positive cells in the nerve injury model. Collectively, our results have demonstrated roles of ROCK in the spinal microglia that is involved in p38 MAPK activation and the morphological changes. Inhibition of ROCK signaling may offer a novel target for the development of a neuropathic pain treatment.

[Time course of changes in gustatory function test results and subjective symptoms, and predictive factors for response in patients with taste disorder receiving 24-week zinc replacement treatment]

In a taste disorder, an agreement between patients' complaints and gustatory function test results is not necessarily found both at the initial hospital visit and during the course of treatment; therefore, it is difficult to assess treatment responses and review treatment strategies based on the assessed treatment responses. The present study investigated the time course of changes in disc gustometry results and subjective symptom scores measured at 4-week intervals in 44 patients with a taste disorder who were considered eligible for zinc replacement treatment and who received polaprezinc at a dose of 150 mg/day (equivalent to a 34 mg/day dose of zinc) for up to 24 weeks. The study also examined the potential differences in treatment outcomes according to the predictive factors for response such as patient background and assessed disc gustometry results during the course of treatment. Results indicated that disc gustometry results and subjective symptom scores showed different time courses of changes. The response rate as measured by disc gustometry was 47.7% at week 12 of treatment, and showed a subsequent slow increase to 56.8% at week 24. On the other hand, subjective symptom scores showed a time-proportional improvement up to week 24. Among the patients included in the present study, a clear difference was found according to the presence or absence of an improving trend as determined by disc gustometry at week 12 of treatment, although there were no differences in ultimate treatment responses, including categories of taste disorder, according to patient background. Patients showing a trend toward improvement had significantly better treatment responses in terms of both ultimate response rates and subjective symptom scores, whereas patients showing no trend toward improvement were less likely to respond to the subsequent 12-week continued treatment.

Is a pulling sensation in the anteroposterior direction associated with otolith dysfunction?

CONCLUSION

A pulling sensation in the anteroposterior direction is suggested to originate from a dysfunction of the otolith organs.

OBJECTIVES

Previous study with vestibular evoked myogenic potential (VEMP) confirmed that a falling sensation (in an up or down direction) and a lateral tilt sensation (in a right or left direction) were caused by otolith lesions. The purpose of this study was to clarify whether a pulling sensation in the anteroposterior (forward or backward) direction originates from otolith dysfunction.

METHODS

The otolith function was assessed by cervical and ocular VEMPs (cVEMPs and oVEMPs) in 12 patients who complained of a forward or backward pulling sensation. cVEMPs were evaluated by the asymmetry ratio (AR) of the amplitude of the p13-n23 wave and the peak latencies of the p13 and n23 waves. oVEMPs were evaluated by the AR of the amplitude of the n1-p1 wave and the peak latency of the n1 and p1 waves.

RESULTS

Abnormal ARs on cVEMP were observed in 7 of 12 patients. Nine of 12 patients had abnormal oVEMP results including 3 bilateral absent responses. Most (10 of 12) patients had abnormal cVEMP and/or oVEMP results. The latency of each detected wave was within the normal ranges.

Therapeutic evaluation of outpatient submucosal inferior turbinate surgery for patients with severe allergic rhinitis

BACKGROUND

Surgical treatment for inferior turbinate (IT) is selected to treat severe allergic rhinitis (AR) that is unresponsive to conservative treatment. This study aimed to determine the clinical effects of outpatient submucosal IT surgery (OSITS) on patients with severe AR.

METHODS

Between January 2008 and August 2012, 95 patients with severe AR who underwent OSITS at the Department of Otolaryngology, Hyogo College of Medicine, were retrospectively analyzed. There were 53 men and 42 women. Their mean age was 27 years (11-75 years). OSITS was bilaterally performed using a bipolar radiofrequency electrocautery under local anesthesia. Symptoms, QOL, and physical findings were evaluated using scores from both pre- and postoperative periods (average: 12.4 months), according to Practical Guideline for the Management of AR in Japan 2009.

RESULTS

In perennial AR, all mean scores of nasal symptoms, QOL, and physical findings significantly improved after OSITS (p < 0.05, n = 83). Nasal obstruction, sleep problems, and IT congestion were the most strongly affected. Eye symptoms were not influenced by OSITS. OSITS also showed significant effects on nasal obstruction and IT congestion in seasonal AR (p < 0.05, n = 12), but not sneezing, nasal discharge, and QOL. In terms of the efficacy, OSITS was beneficial in 90% of perennial AR cases and 75% of seasonal AR cases. Epistaxis (1%), vestibulitis (1%), and IT atrophy (4%) were observed after OSITS.

CONCLUSIONS

These data indicate that OSITS using radiofrequency electrocautery could be a beneficial therapeutic option in patients with severe AR.

[The effect of zinc agent in 219 patients with zinc deficiency-inductive/ idiopathic taste disorder: a placebo controlled randomized study]

Diagnosis and treatment of taste disorders are challenging because the disorder can only be determined by the awareness of the patient. Hence, these disorders still require comprehensive evidence. We conducted a randomized, placebo-controlled double-blind study to investigate the effect of polaprezinc, a zinc-containing agent, in 219 patients with either zinc deficiency-inductive or an idiopathic taste, disorder. As a result, the zinc-treated arm experienced a statistically significant improvement against the placebo-treated arm in the perceptible threshold scores of the filter-paper disk method 8 weeks after the administration of the investigational drug. Moreover, the effect lasted for 4 weeks after discontinuation of the drug. However, the effective ratios based on the initial criteria were 55.6% in the treatment group and 43.2% in the placebo, where no statistical significance was recorded. Sex and degree of depression could be two of the potential factors to explain this discrepancy. Furthermore, the effect was not significant among male patients and patients with a high depression score based on the Self-rating Depression Scale (SDS) test. These results indicate that determining the symptom among such patients remains undisclosed. Whereas, in approximately 77%, or 168 patients with "normal" SDS scores and with completely impaired taste qualities, the ratio of effective cases reached 60.9% in the zinc-treated group, the ratio of the placebo-treated group reached 39.5%, resulting in a statistical significance. This may be partly because of a problem in the adaption of male subjects to the gustatory analyses, especially to the identification of saltiness and sourness. Care must also be taken regarding the depressive state of patients when diagnosing and treating taste disorders. Taste disorders caused by depression may not be cured by zinc supplementation due in part to the fact that the symptom is based on a mental issue, and due in part to the conservative responding bias generated by the depression itself, which may inhibit accurate and precise diagnosis of the disorder. In conclusion, administration of a zinc agent is effective for patients with taste disorders, provided selection of appropriate patients is performed, and that proper examination and evaluation are conducted. The present study also indicated that examining depressiveness based on the SDS scores and investigating disturbance of each taste quality using the filter-paper disk method are recommended for the diagnosis and determination of the treatment effect of a taste disorder.

Risk Factors for Cervical Lymph Node Metastasis of Tongue Carcinoma to the Unaffected Side

Objectives:

Investigate the relationship between cervical lymph node metastasis of tongue carcinoma in unaffected and affected sides and factors related to the primary site.

Methods:

Between January 2000 and December 2009, 248 patients with primary N0 tongue carcinoma in the unaffected side were treated radically at the Department of Otolaryngology, Osaka Medical Center for Cancer and Cardiovascular Diseases. We evaluated clinical T stage, tumor size, tumor extension (oral floor, anterior part of the tongue, root of the tongue, depth into the tongue) and clinical N stage for risk factors influencing cervical lymph node metastasis to the unaffected side.

Results:

Fourteen of 248 patients (5.6%) showed cervical node metastasis in the unaffected side. The rate of metastasis to the unaffected side was 17% in patients with primary site extending to the anterior part of the back of the tongue ( P < 0.01). The rate was 16% in patients with primary site extending to more than half of the tongue depth ( P < 0.05). The rate was 14% in patients with cN+ in the affected side ( P < 0.01). Other factors were not associated a significant difference.

Conclusions:

Extending to the anterior part of the back of the tongue, more than half of the tongue depth and cN+ in the affected side were high risk factors of cervical lymph node metastasis to the unaffected side.

CD44 Expression in Biopsy Specimens of Patients with Nasopharyngeal Carcinoma Is Associated with Prognosis

Objectives:

CD44 is a major cancer stem cell marker, and it has been reported to be associated with biological malignancy in several cancers. However, the potential oncogenic role of CD44 and its clinical/prognostic significance in nasopharyngeal carcinoma (NPC) are unclear. In this study, we evaluated the association of CD44, especially its variant isoforms V3 and V6, with prognostic factors in NPC patients. We examined CD44 expression by immunohistochemical analysis of biopsy specimens obtained from 42 NPC patients who underwent treatment.

Methods:

The subjects were 42 patients (35 men and 7 women; average age, 56.3 years) who received concurrent chemoradiotherapy (CCRT) consisting of chemotherapy (CBDCA or CDGP or DOC) and radiation therapy (60-66 Gy) as an initial treatment. Thereafter, the biopsy specimens from these patients were examined immunohistochemically to study the association between CD44 expression (V3, V6) and prognosis of NPC.

Results:

High CD44 (V3, V6) expression was significantly correlated with increased clinical incomplete response to CCRT at the primary site ( P = 0.008 in V3 and V6 by χ2-test) and poor disease-specific survival ( P = 0.0003 in V3 and P = 0.0029 in V6 by log-rank test). However, distant metastasis showed no association with CD44 expression.

Conclusions:

High expression of CD44 (V3, V6) is associated with poor prognosis in patients with NPC. Evaluation of CD44, especially the variant isoforms V3 and V6, may be useful for predicting tumor response to CCRT and prognosis of patients with NPC.

Detection of utricular dysfunction using ocular vestibular evoked myogenic potential in patients with benign paroxysmal positional vertigo

BACKGROUND

The ocular vestibular evoked myogenic potential (oVEMP) is thought to originate from the contralateral utricular organ. However, the clinical use of oVEMP has not yet been established. This study aimed to clarify whether oVEMP could be used to detect utricular dysfunction in patients with benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHODS

Sixteen patients with BPPV underwent oVEMP measurements. Recordings were made on 2 separate occasions: when typical nystagmus was confirmed (pretreatment oVEMP) and 1 week after performing Epley's maneuver (posttreatment oVEMP). Results were evaluated using the asymmetry ratio (AR) of n1-p1 wave peak-to-peak amplitude and defined as reduced oVEMP when AR was >31.6%, or augmented oVEMP when AR was <-31.6%.

RESULTS

Bilateral responses were recorded in 13 patients on the pretreatment oVEMP. Abnormal results were found in 11 patients (84.5%). These included 5 patients with reduced response and 6 with augmented response. On the posttreatment oVEMP, abnormal results were found in 5 patients (38.5%). All indicated reduced oVEMP. Abnormal results on the pretreatment oVEMP were not related to any persistent positional vertigo (p>0.05, Fisher's exact test). Three out of 4 patients (75.0%) with continuing unsteadiness had abnormal results (reduced response) on the posttreatment oVEMP.

DISCUSSION

The oVEMP measurements indicated abnormal function of the utricle in patients with BPPV. Reduced oVEMP is thought to originate from the partial degeneration of utricular hair cells. Conversely, augmented oVEMP in the affected ear is thought to originate from a hypermobility of the stereocilia due to the detachment of otoconia within the utricle. The above-mentioned utricular dysfunction should be independent of the existence of otoconia in the semicircular canal; thus, the results of oVEMP were not related to the recovery of symptoms.

CONCLUSION

oVEMP can be reliably used to detect utricular lesions in patients with BPPV.

Psychological condition in patients with intractable Meniere's disease

CONCLUSIONS

Physicians should consider additional treatment strategies for Meniere's disease patients with a long history of disease and hearing loss in the secondary affected ear and also provide psychological support regarding future progressive bilateral hearing loss.

OBJECTIVES

To treat intractable Meniere's disease patients effectively, we need to understand the psychological condition of each patient. We examined the state of neurosis and depression in patients and correlated this with demographic and background information.

METHODS

Between 1998 and 2009, we enrolled 207 patients with intractable Meniere's disease in this prospective study. We used the Cornell Medical Index and the Self-rating Depression Scale to evaluate their psychological condition. We also obtained demographic and background information relating to sex, age, duration of disease, vertigo frequency, hearing level in bilateral sides, and plasma vasopressin level.

RESULTS

Neurosis and depression was diagnosed in 40.1% and 60.4%, respectively, of patients with intractable Meniere's disease. Our results showed that surgical treatment significantly improved vertigo and hearing ability in patients with no psychological symptoms compared with those exhibiting psychological symptoms. Patients with a longer duration and worse hearing level in the secondary affected ear had a significantly higher incidence of mental illness than those with a shorter duration and better level of hearing.

Analysis of benign paroxysmal positional nystagmus in children

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. However, BPPV in children has been studied less extensively than in the adult population. This is because the observation of benign paroxysmal positional nystagmus (BPPN) in children is technically very difficult and BPPV is rare in children. In this study, we present the only two cases of BPPV in children in which we successfully recorded and analyzed the BPPN.

METHODS

One case was an 11-year-old boy and the other was a 3-year-old girl. We analyzed their BPPN three-dimensionally.

RESULTS

Apogeotropic positional nystagmus was observed in the first case. We analyzed it to verify the presence of cupulolithiasis in the horizontal semicircular canal (HSCC). Geotropic positional nystagmus was observed in the second case, and the analyzed data indicated the presence of canalolithiasis in HSCC. Over the last decade, we have examined 3341 patients complaining of vertigo or dizziness. Among them, there were 63 children with the same complaint, so that the proportion of cases of BPPV in children was only 3% (2/63).

DISCUSSION

Among patients complaining of vertigo or dizziness, children with BPPV are rare (3%). However, we have recorded their BPPN to confirm that BPPV does occur in children and that their characteristics of positional nystagmus are generally identical to those in adults. We emphasize that this is the first report of a child as young as 3 years old being diagnosed with BPPV.

Olfactory changes after endoscopic sinus surgery in patients with chronic rhinosinusitis

OBJECTIVE

To address the controversy over whether olfactory function is improved or not after endoscopic sinus surgery (ESS) in patients with eosinophilic (ECRS) and non-eosinophilic chronic rhinosinusitis (non-ECRS).

METHODS

Between June 2006 and March 2012, 89 adult patients with CRS underwent ESS at Hyogo College of Medicine. There were 55 men and 34 women with a mean age of 53 years old, ranging from 23 to 79 years. The average follow-up period was 10.7 months (3-24) after ESS. Peripheral blood examination, sinonasal CT imaging, and four kinds of olfaction tests [self-administered olfaction test (SAOQ), visual analog scale (VAS), T&T recognition threshold tests (T&T) and intravenous olfaction test using prosultiamine] were performed. We diagnosed ECRS when (i) symptoms of nasal congestion and olfactory disorder, (ii) bilateral chronic rhinosinusitis with nasal polyps (CRSwNPs), (iii) peripheral blood eosinophilia (>7.0%), and (iv) ethmoid sinus dominant opacification in preoperative CT findings (i.e. ethmoid sinuses (E) were more bilaterally occupied than those of maxillary sinuses (M), E/M≥1), were completely fulfilled. We divided the patients into two groups of ECRS (group A) and non-ECRS (group B). Olfaction tests before operation, and at the 3rd, 6th, 12th, and 24th month postoperation were analyzed. The severity and therapeutic evaluation of olfaction were based on criteria of T&T recognition thresholds.

RESULTS

The mean SAOQ and VAS scores showed significant improvement within 6 months after ESS in both group A and group B. In total, the improvement rates were 52.0% (26/50) at 3 months, 58.5% (24/41) at 6 months, 40.5% (15/37) at 12 months, and 41.2% (7/17) at 24 months. The significant improvement of T&T recognition thresholds in group B was maintained for 24 months, whereas those in group A, showing transient improvement, deteriorated after 12 months or more. A significant difference in postoperative T&T recognition between groups A and B was found at the 12th postoperative month. In both A and B, 84% of patients had a response to prosultiamine (positive group) in the preoperative stage. T&T thresholds in the positive group were significantly better that those in the negative groups in the postoperative stage.

CONCLUSION

Olfactory disorders due to ECRS showed transient improvement that deteriorated as time passed after surgery. The olfaction in the non-ECRS patients recovered comparatively well. Postoperative olfactory results were unfavorable in patients without a preoperative reaction to prosultiamine.

Vestibular-evoked myogenic potential in response to bone-conducted sound in patients with otosclerosis

Conclusion:

Saccular dysfunction is a major cause of balance problems in patients with otosclerosis. Vestibular-evoked myogenic potential in response to bone-conducted sound (BC-VEMP) testing is useful for diagnosis of these patients.

Objectives:

The purpose of this study was to elucidate the origin of balance problems in patients with otosclerosis using BC-VEMP.

Methods:

Subjects comprised 25 patients with unoperated otosclerosis (9 men and 16 women). They were divided into two groups depending on type of balance problems. Results of cochleo-vestibular functions including pure-tone audiometry, caloric testing, and BC-VEMP testing were compared between the two groups.

Results:

Ten patients had complained of dizziness and/or vertigo (disequilibrium group), and the other 15 patients had not (Non-disequilibrium group). Nine patients showed abnormal results on BC-VEMP testing in the disequilibrium group, while one patient had abnormal results in the non-disequilibrium group (p < 0.001).

Endoscopic Scoring after Endoscopic Sinus Surgery

Objective: 1) Propose a simple endoscopic scoring after endoscopic sinus surgery (ESS). 2) Show the usefulness of the scoring in the postoperative evaluation.

Method: Eight-six patients with chronic sinusitis who underwent ESS were enrolled. The patients consisted of 65 men and 21 women, and the mean age was 52.7 years. Fourteen patients with bronchial asthma were included. The postoperative endoscopic scoring (E score) was performed at 1 year after surgery in all patients.

Results: E score was assessed in a similar manner as Lund-Mackay CT score. The physical findings of each sinus via the opening were scored; 2 points when the opening was closed, 1 point when the sinus was diseased, 0 point when normal. E score is expressed as a percentage of the maximum score possible. E scores in the patients showed a statistical correlation with the postoperative CT scores ( P < .001). The mean E score showed 22.5%, and was close to the postoperative CT score (20.5%). The mean E score in patients without asthma showed statistically better outcomes than with asthma.

Conclusion: A simple endoscopic scoring after ESS has been required although several evaluation methods were advocated. E score is a simple and useful postoperative evaluation method as same as Lund-Mackay CT score in patients after ESS.

Long-term Surgical Results of Semicircular Canal Fistulae

Objective: Although many studies report short-term hearing results after surgically managing semicircular canal fistulae, long-term results are still unknown. In the present study, long-term postoperative hearing outcomes were reviewed in 14 ears of patients with cholesteatoma and semicircular canal fistulae.

Method: Between 1996 and 2010, 84 patients with cholesteatoma and semicircular canal fistulae underwent tympanoplasty at Hyogo College of Medicine Hospital. The location of the fistula was the lateral semicircular canal in all cases and superior semicircular canal in 5 cases. Fourteen patients were followed up for more than 5 years.

Results: Postoperative air-bone gap was ≤10 dB in 1 case, between 11 and 20 dB in 7 cases, between 21 and 30 dB in 4 cases, and ≥31 dB in 2 cases. Mean bone-conduction hearing levels on the operated side had deteriorated by 3 dB in 1 kHz, by −1 dB in 2 kHz, and −2 dB in 4 kHz at 1 year postoperatively and by 8 dB, 6 dB, and 2 dB at 5 years postoperatively, respectively. Bone-conduction hearing levels in 1 and 2 kHz were significantly deteriorated at 5 years postoperatively, compared with baseline and 1-year ( P < .05).

Conclusion: Even if the semicircular canal fistula is surgically managed, bone-conduction hearing level gradually deteriorates in the 1- and 2- kHz ranges over the long time.

Inferior Turbinate Surgery for Severe Allergic Rhinitis

Objective: Inferior turbinate surgery, an outpatient surgery, is used to treat severe allergic rhinitis that is unresponsive to medication. The purpose of this study was to determine the clinical effects of outpatient inferior turbinate surgery (OITS) on patients with severe allergic rhinitis.

Method: Between January 2008 and December 2011, we performed OITS bilaterally under local anesthesia for 216 patients with severe allergic rhinitis. Two kinds of cautery device, high-frequency electrocautery and argon plasma coagulation, were used. Nasal symptoms and intranasal findings were evaluated pre- and postoperatively at 3 months or more after OITS.

Results: On average, scores for sneezing, nasal discharge, and nasal obstruction significantly improved from 1.3 to 0.8, from 1.7 to 1.1, and from 2.6 to 1.2 ( P < .001, n = 216), respectively. Overall, improvement of symptoms was found in 73% (157/216 patients) postoperatively. Congestion of inferior turbinates also improved in 74% (160/216 patients).

Conclusion: These data indicate that the OITS had an effect on more than 70% of patients with severe allergic rhinitis.

[Staging-based surgical results in chronic otitis media with cholesteatoma]

Discussions of surgical results in chronic otitis media involving cholesteatoma usually include hearing improvement, side effects, and cholesteatoma recurrence, although such talks could easily involve the influence on surgical results of the intraoperative extension of the cholesteatoma-affected area around the tympanomastoid cavity. Based on intraoperative chronic otitis media staging involving cholesteatoma proposed by the Japan Otological Society in 2010, we studied our tympanoplasty results between April 1997 and March 2010. Hearing improvement in all subjects with pars flaccida cholesteatoma was 79.0% (n= 100) and that with pars tensa 73.3% (n = 30)--results not significantly influenced by intraoperative staging grade but significantly dependent on stapes presence (tympanoplasty type I and III) or absence (type IV). Nine cases of recurrence were seen in pars flaccida and four in pars tensa. Intraoperative side effects and postoperative recurrence often occurred in advanced cases. These findings suggest that intraoperative chronic otitis media staging involving cholesteatoma may make it important to be aware of the need for more careful procedures during surgery and in follow-up.

Furosemide-loading vestibular evoked myogenic potential testing can suggest developing bilateral involvement of unilateral Meniere's disease

CONCLUSIONS

Patients with positive results of furosemide-loading vestibular evoked myogenic potential (F-VEMP) testing in the unaffected ears of unilateral Meniere's disease have a high incidence of developing bilateral lesions.

OBJECTIVE

To clarify the meaning of positive results of F-VEMP testing of the unaffected ear of patients with unilateral Meniere's disease.

METHODS

Twenty-five patients with unilateral Meniere's disease were investigated in this study. The positive group consisted of 6 patients with positive results of F-VEMP testing in the contralateral ear and the negative group consisted of 19 patients with negative results. The incidence of contralateral involvement was compared in both groups by the Kaplan-Meier method.

RESULTS

Contralateral involvement was seen in three cases (50%) in the positive group after 2, 12, and 26 months and in three cases (16%) in the negative group after 27, 56, and 78 months. The positive group had a higher incidence of contralateral involvement than the negative group (p = 0.0017, according to a log-rank test).

Combined small cell carcinoma of the hypopharynx

We report an extremely rare case of combined small cell carcinoma (combined SmCC) of the hypopharynx. A 73-year-old male presented with multiple left neck swellings for 1 month. A tumorous lesion was found in the left pyriform sinus, and biopsy revealed that the lesion was squamous cell carcinoma (SqCC). Surgery was performed and pathological examination led to a diagnosis as combined SmCC, composed of SqCC and small cell carcinoma (SmCC). One month after surgery, a contrast-CT indicated metastases to the cervical lymph node (LN), mediastinum and liver. We performed 5 courses of chemotherapy with the use of cisplatin (CDDP) and irinotecan (CPT-11). The patient temporarily showed a favorable response to the chemotherapy; however, eventually he died of regrowth of the tumor. Combined SmCC is a disease with a poor prognosis. Although biopsy sometimes fails to detect the SmCC component, intensive diagnosis and treatment are necessary.

Clinical Study of 1304 Patients with Epistaxis for Recent 5 Years

Objective: Epistaxis is one of the most common symptoms encountered in the ENT clinic. In this study, we reviewed our recent clinical experience of patients with epistaxis and discussed important lessons for the management of cases of epistaxis.

Method: Between 2005 and 2009, 1304 patients with epistaxis were treated at our department. There were 795 men and 509 women. Mean age was 57 years (range, 0-99 years). Clinical features: situations at the first visit; pathogenesis; bleeding points; methods of treatments; and clinical courses were retrospectively investigated.

Results: The 700 patients (54%) first visited in the nighttime. The most common condition was hypertension in 388 patients (30%) followed by cardiovascular disease in 262 patients (20%). The 630 patients (48%) were on medication with hypotensors and/or antithrombotic drugs. Kiesselbach’s plexus was the mostly observed, as it was observed in 679 patients (52%). In 225 patients (17%), bleeding point was not confirmed. The 424 patients (33%) were primarily treated by anterior packing, followed by electrocauterization in 365 patients (28%). Re-bleedings within 14 days after the primary treatments were found in 181 patients (14%). Hospitalized surgical treatments were required in 3% (6/181 patients).

Conclusion: Outpatient therapy is usually enough to arrest hemorrhage in major cases. However, we have encountered patients with repeating arterial pulsing bleedings who require emergent hospitalized surgical therapy. Risk of re-bleeding within a day should be considered if patients had uncertain bleeding point and circulatory diseases.

Endolymphatic Sac Assessed by 3D Cone Beam CT in Ménière Disease

Objective: The poster introduces new 3D Cone-beam CT (CBCT) images of endolymphatic sac (ELS). The volume rendering provides realistic image of ELS in relation to the semicircular canal, enabling one to assess location, size, and shape preoperatively. The results are compared with operative findings to confirm clinical values of the new imaging technology.

Method: The 3D Cone-beam CT images of the 12 patients with Ménière diseases who underwent an endolymphatic mastoid shunt operation between 2008 and 2011 were obtained at our hospital. We assessed location, size, and shape of the ELS. The results of preoperative assessments were compared with the operational findings.

Results: First we present clear and sharp 3D pictures of ELS and the semicircular canal using volume rendering incomparable to conventional CT. In 11 patients, the ELS was located exactly along the Donaldson line. In one patient, it was located inferiorly to the line. Size of the ELS was moderate in 6 patients, small in 5, and exceedingly small in 1. Cross section of the sac was circular in 3 patients, oval and flat in 8, and unverified in 1 because the size was too small. The above findings agree with the operational findings closely.

Conclusion: In 3D Cone-beam CT, we could get more informative and better quality images than in conventional CT. Thanks to the preoperative realistic 3D images of ELS and the semicircular canal, we could perform the sac operation more safely and easily. Imaging information thus obtained may help deepen the understanding of Ménière’s disease.