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Surgical removal of tumor is the primary treatment of choice for glomus tympanicum (GT). However, because the tumor has abundant blood flow, bleeding control is crucial, and preoperative embolization may be performed. Here, we report the case of a 46-year-old female who visited our hospital with a complaint of right pulsatile tinnitus. A red pulsatile mass was found in the right tympanic cavity, and she was diagnosed with class B1 GT and subsequently underwent surgical treatment. We judged that bleeding could be controlled by intratympanic cavity manipulation alone and decided to perform transmeatal tumor resection without preoperative arterial embolization. After creating a tympanomeatal flap and performing an atticotomy, some pieces of Spongel(®) were inserted between the tumor and the tympanic wall. The Spongel(®) absorbed the blood and created a space between the tumor and tympanic wall, which allowed for the insertion of the tip of the Vesalius(®) handpiece to coagulate the tumor. The coagulation caused the tumor to shrink, thereby widening the space and allowing for further resection. Although the surgical manipulation caused bleeding, complete resection was achieved by the application of Spongel(®) and coagulation with Vesalius(®). Since the tip of the Vesalius(®) was not burned, hemostasis was successfully achieved, and the operation proceeded while maintaining a clear field of view. There was little bleeding and no postoperative complications. The patient was discharged on the sixth postoperative day. One year after surgery, pure tone audiometry showed no change in the level of bone conduction. Spongel(®) and Vesalius(®) are useful tools that allow to safely perform surgeries even in narrow spaces such as the tympanic cavity.

Gorham-Stout disease, a rare and intractable disease of unknown etiology, causes systemic bone lysis and replacement with lymphoid tissue. Here, we report a case of Gorham-Stout disease with cerebrospinal fluid leakage in a 16-year-old boy. The patient complained of nasal discharge, right ear obstruction, fever, and headache. A computed tomography scan of the head showed osteolysis around the right internal carotid artery, vestibule, and cochlea and osteolytic changes in the left parietal bone. It was suggested that the patient had bacterial meningitis owing to the leakage of cerebrospinal fluid from the fistula caused by the temporal bone osteolysis. He was treated with meropenem, and a transmeatal fistula closure and a bone biopsy of the left parietal bone were performed. Intraoperatively, osteolysis was observed on the promontory and around the internal carotid artery. The fistula was closed by dense filling and compression around the fistula, in the middle ear cavity, and in the external auditory canal. The symptoms disappeared after the surgery. Bone biopsy showed the presence of a lymphangioma, and Gorham-Stout disease was diagnosed. Prophylactic bisphosphonate therapy was initiated. A 4-year follow-up revealed no progression of the disease.

Objective Few reports discuss the characteristics of repeated recidivism of cholesteatoma. We describe the clinical characteristics of patients with cholesteatoma who experienced at least two recidivism episodes after initial surgery for cholesteatoma requiring canal wall reconstruction. Methods We reviewed the medical records of 11 patients who underwent surgery for cholesteatoma with canal wall reconstruction at our department between April 2008 and March 2018 and subsequently experienced two relapses that necessitated revision surgery involving tympanomastoidectomy with canal reconstruction. Patient age at the time of the first surgery ranged from 6 to 56 (mean, 25.7) years. Seven (63.6%) of the 11 patients were male. These 11 patients were classified according to the type of recidivism, and their characteristics (pathology, operation date, operation method, pattern of relapse, and position of recurrence) were investigated. Results Four cases involved secondary residual cholesteatoma, with the mean interval between the first revision surgery and the second revision surgery being 23.8 (range, 11–39) months. Secondary residual sites included the anterior tympanic cavity, tympanic sinus, and anterior end of the reconstructed cartilage of the canal wall. The other seven cases involved secondary recurrence, with the mean interval between the first and the second revision surgery being 26.1 (range, 12–57) months. The sites of recurrence were at the edges of the reconstructed cartilage. One notable case involved the cartilage junction, leading us to hypothesize that retraction of the temporal muscle flap and the patulous Eustachian tube was the underlying cause. Conclusion For residual cholesteatoma, strict measures are necessary to maintain the operation under clear view, and more careful follow-up is necessary in patients who have had previous surgery at another hospital. For recurrent cholesteatoma, it was recognized that Eustachian tube function must be ascertained in advance, and careful observation of the reconstructed cartilage edge is necessary.

A 75-year-old female patient presented with a suspected recurrence of a clival chordoma. The tumor was resected using the infratemporal fossa type B and anterior petrosal approach with the help of a neurosurgeon. During cauterization of the trigeminal nerve, the patient developed cardiac arrest for approximately 10 seconds because of the trigemino-cardiac reflex (TCR). After several sternal compressions, there was return of spontaneous circulation. The operation was resumed after the circulatory dynamics stabilized. Subsequently, the surgery was completed with partial resection of the tumor without the recurrence of cardiac arrest. The pathological diagnosis was chondrosarcoma, and postoperative treatment with radiotherapy was started. Stimulation of the sensory branches of the trigeminal nerve induces TCR. There are reports of TCR developing in approximately 10% of skull base surgery cases in the absence of atropine administration. We report a rare case of TCR during the surgical procedure for the treatment of a skull base chondrosarcoma.

[Background] Postoperative hearing results of type IV tympanoplasty have been shown to have poorer results than other reconstruction techniques. There are numerous reports evaluating the factors for hearing improvement. This preliminary study aimed to analyze and determine the factors that affect hearing results. [Methods] A total of 80 patients who underwent type IV tympanoplasty were evaluated to participate in this study. The medical records of the candidate patients were collected retrospectively. Fifty out of the 80 recruited patients were excluded due to the following reasons: they could not be followed-up for more than a year after the final operation, their initial surgery was not performed in our department, or they needed a revision surgery. The pre-, intra-, and postoperative factors were evaluated and analyzed using EZR software. Cases were divided into two groups according to postoperative hearing results, and each factor was analyzed univariately. The explanatory variables included in the multivariate analysis were the variables that satisfied P < 0.1 in the univariate analysis. Furthermore, all cases were divided into two groups according to the qualitative variables that showed significant difference in the multivariate analysis, and the background factors were evaluated. [Results] The results of univariate analysis showed P < 0.1 for ‘Age’ and ‘Material of external auditory canal (EAC) packing’. Multivariate analysis showed P < 0.05 for both. The comparison between the two packing material groups showed that the gauze group was more likely to have improved hearing than Spongel? group, and the ossicular chain condition of the gauze group was maintained better. [Conclusion] ‘Age’ and ‘Material of EAC packing’ were considered to be significant factors affecting the postoperative hearing results. The selection and use of packing materials that provide stability should be considered to obtain better postoperative hearing results in type IV tympanoplasty.

Background Anaplastic thyroid carcinoma (ATC) is an aggressive type of thyroid cancer, and its metastasis requires cell motility. Ceramide is involved in a variety of biological processes, including inflammation, cell signaling, cell motility, and induction of apoptosis, however has not previously been reported to inhibit the motility of ATC cells. We evaluated the effect of short chain C6-ceramide on motility of ATC cells. Methods Cell motility of 8305C thyroid carcinoma cell line treated with C6-ceramide was assessed using a transwell migration assay and a pseudopodia formation assay. Results Treatment with 10 µM C6-ceramide resulted in significantly fewer migratory cells than control treatment in a transwell migration assay (P < 0.002). In condition medium, 82.6% of C6-ceramide-treated cells formed lamellipodia. Importantly, treatment with 10 µM C6-ceramide drastically decreased the number of cells forming lamellipodia by 17.6% (P < 0.01). Conclusion Our results suggest that treatment with a low concentration of ceramide may prevent metastasis and recurrence of ATC by inhibiting cell motility. Further studies are necessary to investigate the mechanism of inhibition of cell motility by ceramide. Ceramide shows promise as a therapeutic treatment for ATC.

[Background] Endoscopic surgery is developing in various clinical specialties. During ear endoscopic surgery, a surgeon has to hold an endoscope with one hand and operate the surgical instruments with another hand. Therefore, the stability of the surgeon’s hand affects the field of surgical view and quality of the surgery considerably. There are few techniques which are used during surgery to stabilize the endoscope. However, no study has evaluated the efficacy of such techniques in detail. This study examined the three dimensional movement of an endoscope to compare and evaluate the effect of various stabilization techniques to reduce the hand tremor while using the endoscope. [Methods] A non-randomized controlled trial involving 15 medical students was conducted in Tottori University, Japan. Subjects held an endoscope with their non-dominant hand and manipulated it using three different stabilization techniques i.e. with resting the elbow on the table, resting the endoscope on the ear canal, both with the elbow on the table and endoscope on the ear canal. For the control, subjects were made to use the endoscope without any stabilization technique. The endoscopic movement was measured with and without using the stabilization techniques. [Results] The results obtained in this study indicated that manipulating the endoscope with resting the elbow on the table restrains both vertical (Y-axis) and optical axis (Z-axis) direction of tremor, and manipulating the endoscope by resting it on the ear canal restrains both vertical (Y-axis) and horizontal axis (X-axis) direction while the combined use of both the techniques reduces the endoscope movement in all the three X, Y and Z axes. [Conclusion] In conclusion, concomitant use of both techniques appears to be clinically beneficial in endoscopic ear surgery.

Background Cartilage conduction hearing aids (CCHAs) were newly devised and spread fast in Japan since their launch in 2017. However, little knowledge is available for this new device. Purpose The aim of this study was to establish the knowledge of CCHAs and suggest their indication. Research Design Correlational study. Study Sample A total 256 patients were registered. Data Collection and Analysis The fitting of CCHAs was surveyed in nine institutions. The outcomes were assessed by audiometric tests. The patients were classified into seven groups, depending on the ear conditions. The clinical characteristics, assessment results, and purchase rates were compared among the groups. The assessment results of CCHAs were also compared with those of previously used hearing aids. Results Most patients who used CCHAs were classified into the bilateral closed (aural atresia or severe stenosis) ear (n = 65) or unilateral closed ear (n = 124) groups. The patients in these groups achieved good benefits that resulted in a high purchase rate. The bilateral continuous otorrhea group also supported a high purchase rate, although the benefits of CCHAs were not always excellent. In contrast, the purchase rate was poor in the patients who could use air conduction hearing aids (ACHAs) without absolute problems. As for using a CCHA as a contralateral routing of signals hearing aid, the benefits depended on the patients. Conclusions CCHAs are considered as a great option not only to the patients with closed ears but also to those who had difficulties in ACHAs usage.

Superficial siderosis is a disease in which iron from hemoglobin is deposited in the central nervous system, resulting in conditions such as progressive sensorineural hearing loss, cerebellar ataxia, dementia, and pyramidal signs. A 30-year-old man with superficial siderosis received a cochlear implant in the left ear, which had shown complete hearing loss. Good auditory responses were obtained at 14 days after implantation. The postoperative average hearing level with the cochlear implant was 56.7 dB at 3 months and 55.0 dB at 6 months. However, the patient showed gradual hearing loss, and the dynamic range changed each time the electrode parameters were adjusted. To assess residual hearing ability, single-photon emission computed tomography was performed together with an assessment of electrical auditory brainstem response, which showed a good response and increased blood flow in both the temporal lobes. Based on this result, we asked the patient to continue using the cochlear implant to see whether a perception of speech response would be obtained. However, the patient discontinued using the cochlear implant because he could not hear satisfactorily. Hearing outcomes after cochlear implant surgery for patients with superficial siderosis are not necessarily good. Therefore, the possibility of unsatisfactory results should be fully explained before recommending this surgery to patients.

In order to help a surgeon make the best decision, a more objective method of measuring ossicular motion is required.A laser Doppler vibrometer was mounted on a surgical microscope. To measure ossicular chain vibrations, eight patients with cochlear implants were investigated. To assess the motions of the ossicular chain, velocities at five points were measured with tonal stimuli of 1 and 3 kHz, which yielded reproducible results. The sequential amplitude change at each point was calculated with phase shifting from the tonal stimulus. Motion of the ossicular chain was visualized from the averaged results using the graphics application.The head of the malleus and the body of the incus showed synchronized movement as one unit. In contrast, the stapes (incudostapedial joint and posterior crus) moved synchronously in opposite phase to the malleus and incus. The amplitudes at 1 kHz were almost twice those at 3 kHz.Our results show that the malleus and incus unit and the stapes move with a phase difference.

Endoscopic ear surgery (EES) has, in recent years, become more widely adopted by ear surgeons. Important benefits of an endoscope over a microscope include the wide field of view of the middle ear afforded by the light source located at the tip of the instrument and the availability of angled lenses. Furthermore, middle ear procedures using an endoscope can reduce the need for drilling in the operative field [1]. During EES, the operator holds the endoscope with one hand and manipulates the instruments with the other. However, maintaining endoscope stability can be difficult, particularly for operators with insufficient experience in endoscopic surgeries. Such instability of the endoscope can cause surgical difficulties, and increase the risk of complications resulting from contact with important surrounding structures. In other fields where access to the surgical field is relatively wide, an assistant surgeon often holds the endoscope with both hands to maintain a good view. In contrast, using an assistant to keep the endoscope stable in EES is very difficult, because the endoscope and instruments pass through the same hole, the external auditory canal (EAC). As the intraoperative monitor only provides a 2-dimensional image, the operator cannot judge how far the endoscope is displaced parallel to the visual axis. Few reports have examined the impact of hand tremor during surgery, and none appear to have investigated endoscope displacement during EES. This study established a method to measure 3-dimensional displacement of the endoscope in an objective manner and then measured endoscope displacement under different conditions of endoscope fixation to analyze appropriate fixation during EES.

To investigate the usefulness of magnetic resonance imaging (MRI) including three-dimensional (3D) sequences in the differentiation between Bell's palsy (BP) and Ramsay Hunt syndrome (RHS).A prospective study.Tertiary care center.Twenty patients: 15 patients with BP and five patients with RHS.Diagnostic.Clinical diagnosis (BP or RHS).The presence of hyperintensity on 3D-fluid-attenuated inversion recovery sequence (3D-FLAIR) and enhancement on gadolinium-enhanced (CE)-3D-FLAIR and CE-3D-T1-weighted image (3D-T1WI) along the internal auditory canal (IAC) wall were significantly associated with RHS (p 0.05). Hyperintensity in the inner ear was observed on pre- and postcontrast 3D-FLAIR, and enhancement of the cranial nerve (CN)-VIII was observed only on CE-3D-FLAIR. The presence of these findings also showed significant relationships with RHS (p 0.05). Moreover, thickening of the CN-VII in the fundus of the IAC in 3D-constructive interference on steady state sequence (3D-CISS) also showed a significant association with RHS (p 0.05). In contrast, the presence of hyperintensity of the CN-VII in the fundus of the IAC on 3D-FLAIR did not demonstrate a significant relationship (p = 0.95), and enhancement in this region was observed in all cases on CE-3D-FLAIR and gadolinium-enhanced-three-dimensional-T1-weighted gradient echo sequence (CE-3D-T1WI).3D MRI sequences are useful for differentiating RHS from BP. In particular, the enhancement in the CN-VIII and/or along the IAC wall are valuable findings, and CE-3D-FLAIR is the most useful sequence to evaluate these findings. Thickening of the CN-VII on 3D-CISS is also an important finding.

Sphingolipids, components of cellular membranes in eukaryotic cells, have roles in the regulation of tumor growth, inflammation, angiogenesis, and immunity. We investigated the effects of dietary glucosylceramides, sphingolipids isolated from rice bran, on tumor growth of human head and neck squamous cell carcinoma.The tumor cell line SCCKN cells isolated from well-differentiated human head and neck cancer were subcutaneously inoculated into the right flank of NOD/SCID mice, to establish an SCCKN xenograft model. Rice bran glucosylceramides (300 mg/kg/day) were administered orally to the mice for 14 consecutive days.Dietary glucosylceramides significantly inhibited the growth of the xenograft tumor in comparison with the control group. The TUNEL stain revealed that treatment of mice with glucosylceramides increased the number of apoptotic cells in the implanted tumor tissues and that apoptosis induction was accompanied by the formation of active/cleaved caspase-3.These results suggest that dietary glucosylceramides possibly exert anti-tumor activity by inducing apoptosis of head and neck squamous cell carcinoma. Therefore, their potential usefulness in treatment and prevention of human head and neck squamous cell carcinoma warrants further investigation.

耳鼻咽喉科・頭頸部外科医が，気管癌に遭遇する機会は殆んどない。その初発症状は，気管狭窄，喘鳴，血痰などであり，他科において気管支炎や気管支喘息として診断や治療を受けることが多い。このために診断が遅れ，不幸な転帰をとることも少なくない。今回，われわれは，健康診断で発見された，気管腺様嚢胞癌の症例を経験したので報告する。症例は39歳女性，胸部の異常陰影を指摘され，某大学病院呼吸器外科に紹介された。胸部CTにおいて，前縦隔と右頸部に結節状の陰影を認めた。さらに穿刺吸引細胞診検査により，前縦隔の腫瘤は胸腺腫，右頸部の腫瘤は腺様嚢胞癌と診断された。気管支鏡検査においても，声門直下から第7気管輪にいたる間に，腫瘍の浸潤が確認された。同部位からの生検でも，腺様嚢胞癌と診断された。また，PET/CT検査では，前縦隔と甲状腺右葉の背側に，FDGの集積を認めた。MRIでは，気管の右外側壁から，気管の内外に浸潤する腫瘍を認めた。この腫瘍に対する治癒切除術に際して，アプローチは気管支鏡で腫瘍を認めなかった第7気管輪の下方より開始したが，切除断端は陽性であった。切除マージンは迅速病理を繰り返して決定したが，さらに3気管輪の追加切除を要した。また，右反回神経は，腫瘍に巻き込まれており，上方で甲状軟骨を切除し，喉頭内でその分枝を求めて，頸神経ワナとの吻合により再建した。また，食道への浸潤も全層にわたり認めた。しかし，顕微鏡下に粘膜のみを残す切除を，3 cmあまりにわたって施行することにより対処できた。最終的に気道の切除は，右側では声門の直下で，左側では輪状軟骨の下端から第10気管輪までの切除を要した。気管の再建は，鼻中隔軟骨を用いたDP皮弁により，三段階に分けて形成した。現時点で再発を示唆する所見は認めず，音声は良好 (MPT 20秒) である。silent aspirationもなく経過は順調である。

It is extremely rare to develop metastasis of differentiated thyroid carcinoma to the axillary lymph nodes, non-regional lymph nodes. The metastasis is likely lymphogenous because of patients showing metastasis only in the axilla without other distant metastasis. Four of 924 patients with differentiated thyroid carcinoma who underwent curative resection in our institution and Kyoto Medical Center showed metastasis to the axilla (0.43%) during the follow-up until July, 2008 from April, 1981. The patients were aged 61-73 years old, 2 with well-differentiated and 2 poorly-differentiated papillary carcinoma, 1 male and 3 female, with 1 already having distant metastasis at a different site when axillary metastasis became clear. Furthermore, each patient had a history of neck dissection of the ipsilateral VI regional lymph nodes prior to axillary metastasis. Concerning the origin of axillar metastasis, it was previous reported that lymphatic communication is present between the cervical and axillary lymphatic clutches. When orthodromic lymphatic flow is blocked by either previous neck dissection or metastasis around the venous angle, the lymphatic system may go against the flow. The postoperative course and prognosis are presented together with the viewpoint of QOL.

We previously reported that dietary glucosylceramides show cancer-prevention activity in a mouse xenograft model of human head and neck cancer cells (SCCKN). However, the mechanism was unclear. Ceramides, metabolites of glucosylceramides, induce apoptotic cell death in various malignancies. Here, we investigated the inhibitory effects of dietary glucosylceramides on tumor growth in vivo and in vitro. SCCKN were subcutaneously inoculated into the right flanks of NOD/SCID mice. Mice were treated with or without dietary glucosylceramides (300 mg/kg) daily for 14 consecutive days after confirmation of tumor progression. Microvessel areas around the tumor were assessed by hematoxylin–eosin staining and immunohistochemistry of CD31, and, as markers for angiogenesis, protein levels of VEGF, VEGF receptor-2, and HIF-1α were assessed by Western blotting. Mass spectrometry was performed to measure the levels of sphingolipids in mouse serum after treatment with dietary glucosylceramides. Oral administration of glucosylceramides significantly decreased SCCKN growth in the xenograft model with inhibition of angioinvasion. In tumor-invasive areas, VEGF and HIF-1α in the tumor cells, and VEGF receptor-2 in endothelial cells decreased after treatment with dietary glucosylceramides. Dietary glucosylceramides increased serum levels of sphingosine-based ceramides as compared to the control. In SCCKN and UV♀2 cells, C6-ceramide suppressed the expressions of VEGF, VEGF receptor-2, and HIF-1α in vitro. These results suggest that dietary glucosylceramides trigger the de novo pathway of ceramide synthesis, indicating that sphingosine-based ceramide suppresses the growth of head and neck tumors through the inhibition of pro-angiogenic signals such as VEGF, VEGF receptor-2, and HIF-1α.

BACKGROUND Numerous studies have reported sound-induced motion of the tympanic membrane (TM). To demonstrate sequential motion characteristics of the entire TM by noncontact laser Doppler vibrometry (LDV), we have investigated multipoint TM measurement. MATERIALS AND METHODS A laser Doppler vibrometer was mounted on a surgical microscope. The velocity was measured at 33 points on the TM using noncontact LDV without any reflectors. Measurements were performed with tonal stimuli of 1, 3, and 6 kHz. Amplitudes were calculated from these measurements, and time-dependent changes in TM motion were described using a graphics application. RESULTS TM motions were detected more clearly and stably at 1 and 3 kHz than at other frequencies. This is because the external auditory canal acted as a resonant tube near 3 kHz. TM motion displayed 1 peak at 1 kHz and 2 peaks at 3 kHz. Large amplitudes were detected in the posterosuperior quadrant (PSQ) at 1 kHz and in the PSQ and anteroinferior quadrant (AIQ) at 3 kHz. The entire TM showed synchronized movement centered on the PSQ at 1 kHz, with phase-shifting between PSQ and AIQ movement at 3 kHz. Amplitude was smaller at the umbo than at other parts. In contrast, amplitudes at high frequencies were too small and complicated to detect any obvious peaks. CONCLUSION Sequential multipoint motion of the tympanic membrane showed that vibration characteristics of the TM differ according to the part and frequency.

Purpose: We previously reported the usefulness of a qualified highly sensitive detection method for human telomerase reverse transcriptase (hTERT) mRNA in serum with 89.7% sensitivity for hepatocellular carcinoma (HCC). In this study, we developed a quantitative detection method for serum hTERT mRNA and examined the clinical significance in HCC diagnosis. Experimental Background: In 64 patients with HCC, 20 with liver cirrhosis, 20 with chronic hepatitis, and 50 healthy individuals, we measured serum hTERT mRNA by using the newly developed real-time quantitative reverse transcription-PCR with SYBR Green I. We examined its sensitivity and specificity in HCC diagnosis, clinical significance in comparison with other tumor markers, and its correlations with the clinical variables by using multivariate analyses. Results: Serum hTERT mRNA showed higher values in patients with HCC than those with chronic liver diseases. hTERT mRNA expression was shown to be independently correlated with clinical variables such as tumor size, number, and degree of differentiation (P < 0.001, each). The sensitivity/specificity of hTERT mRNA and alpha;-fetoprotein (AFP) mRNA in HCC diagnosis were 88.2%/70.0% for hTERT and 71.6%/67.5% for AFP, respectively. hTERT mRNA proved to be superior to AFP mRNA, AFP, and des-γ-carboxy prothrombin in HCC diagnosis. Furthermore, hTERT mRNA in serum was associated with that in HCC tissue. Conclusions: The usefulness of hTERT mRNA expression in HCC diagnosis and its superiority to conventional tumor markers were shown. Therefore, serum hTERT mRNA is a novel and available marker for HCC diagnosis.