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Aspergillosis, a fungal infection generally acquired by inhaling airborne spores (conidia) of the ubiquitous mold Aspergillus, may cause symptomatic infection such as allergic aspergillosis in young atopic subjects, aspergillomas also called fungus balls, and invasive aspergillosis typically seen in debilitated or immunocompromised subjects. A 71-year-old man who had undergone chemoradiotherapy for malignant lymphoma 12 years earlier was seen for a visual disorder and pain. It was found in computed tomography (CT) and magnetic resonance imaging (MRI) to have a right orbital apex lesion but no paranasal sinus abnormalities. Based on a diagnosis of optic neuritis without a histopathological diagnosis, we started systemic steroid therapy, which only worsened his symptoms. Endoscopic endonasal orbital apex biopsy conducted afterwards for a definitive diagnosis found that the visual disorder was caused by invasive fungal infection, underscoring the importance of pathological examination.

We conducted a questionnaire survey of internal physicians at seven hospitals to investigate the diagnosis and the treatment for sleep apnea syndrome (SAS) in Kagawa and the role of otolaryngologists in these processes. The diagnosis of SAS was made by polysomnography (PSG) at most institutions (six hospitals, 86%). In six hospitals (86%), patients with SAS were treated not only with CPAP but also by surgery and an oral appliance. These results confirm that the otolaryngologist plays important roles in diagnosing lesions in the upper respiratory tract and in providing combinaton therapy for SAS.

It has been widely pointed out that multislice CT (MSCT) is useful in middle ear disease. The evaluation of the pathological state of the middle ear using 3D CT imaging has been reported on up to now. It is well known that 3D CT imaging is susceptible to post-processing artifacts, whereas multiplanar reconstruction (MPR) is less susceptible to these artifacts. The usefulness of 2D CT imaging using MPR in the evaluation of ossicular lesions in middle ear diseases is discussed.MSCT imaging was performed by Aquilion® (Toshiba Medical Systems, Tokyo, Japan). The axial spiral scans were obtained. Dosimetric measurements using a head calibration phantom were performed for evaluating the radiation exposure of the lenses. The acquired high-resolution data were transferred to a workstation (ALATO VIEW, Toshiba).In approximately 90% of ears, MPR image findings of the malleus handle, the incus long process, incudostapedial joint and the superstructure of the stapes were compatible with their operative findings. Ninety-five to 100% of ears without soft tissue shadows around the ossicles showed agreement between the findings of MPR imaging and the operation. The footplate of the stapes in 7 of 48 ears showed a “sclerotic” finding. Five ears had an “erosive” finding. There was no correlation between MPR image findings and the mobility of the stapedial footplate. The results suggest that MPR imaging is valuable for providing information on the ossicles except the stapes footplate.MPR images showed abnormal findings in 29 of 32 ears (91%) with clinical otosclerosis, which showed demineralization located at the region anterior to the oval window corresponding to the fissula antefenestram, whereas the conventional axial images showed abnormal findings in 22 of 32 ears (69%). The results suggest that MPR imaging can detect small lesions in otosclerosis.

Paranasal mycosis is divided into non-invasive and invasive types. The invasive type is rare, but sometimes fatal; it can extend up to the skull base and affect the orbital cavity with bone destruction. We encountered a case of invasive paranasal-skull base mycosis resistant to surgical and pharmacological treatments. A 78-year-old man developed persistent headache and retro-ocular pain in June, 2004, and consulted the Department of Neurosurgery and Otorhinolaryngology, Ritsurin Hospital on July 20. CT scan demonstrated a soft tissue shadow in the ethmoid and sphenoid sinus with bone destruction of the skull base. We performed endonasal endoscopic biopsy on July 30, but we could not open the sphenoid sinus because of bleeding. Therefore, we only opened the bilateral ethmoid sinuses. The result of biopsy showed granulation tissue. On August 11, endonasal endoscopic surgery was performed to obtain biopsy and culture as well as to drain the sphenoid sinus. The second histopathological examination demonstrated a fungus ball. Culture of this fungus ball demonstrated Aspergillus fumigatus. Post-operative CT scan showed the persistent residue of a soft tissue shadow and expansion of a bone defect of the skull base. The patient was referred to Kagawa University for further treatment. Endonasal endoscopic surgery was performed again to remove residual fungus on August 20. Antifungal drug therapies had been administered throughout the treatment period, but we failed to control the fungal disease. The patient died on September 21.

The clinical results in two patients with glomus tumor recently treated in our department are reported. The first case involved a mixed type of glomus tympanicum tumor and glomus jugulare tumor, while the second case showed glomus jugulotympanicum tumor. These were both classified as class C1 according to Fisch's classification. Both cases were treated surgically by an infratemporal fossa approach. Preoperative embolization diminished bleeding. The first case underwent partial tumor removal with postoperative radiotherapy using a γ-knife. The second case underwent total tumor removal.

We report a case of giant aspergillosis of the sphenoid sinus. The patient was a 67-year-old female who presented with a headache. CT and MRI showed an irregular shadow in the sphenoid sinus and partial bone destruction of the sinus wall. Histopathlogical examination of an intranasal biopsy specimen revealed aspergillus. Endoscopic intranasal sphenoidostomy was performed to drain the sinus and for observation. Histopathlogical examination of the fungus ball also showed aspergillus, which was not invasive to the submucosa tissue. The patient was successfully treated with surgical debridement of the involved sinus and nasal saline irrigation.

The use of long-term middle ear ventilation tubes (Paparella type II) was retrospectively analyzed in 66 ears with otitis media with effusion, in children treated at Kagawa Medical University Hospital between January 1990 and March 1998. The average intubation period was 23.9 months. The average pure tone air conduction threshold showed a remarkable improvement of between 32.7dBHL and 16.9dBHL. Otorrhea was observed in 25 ears (37.8%), obstruction in 2 ears (3.0%), granulation in 3 ears (4.5%) and permanent ear drum perforation in 11 ears (19.6%). No cholesteatma or adhesion of the ear drum was seen. Recurrence of otitis media with effusion was found in 9 of 45 ears (20.0%). In conclusion, Paparella type II tube can be placed for a long-term period and have a low rate of reccurence, but have a high rate of otorrhea and permanent ear drum perforation.

Eight patients with malignant melanoma of the head and neck were treated in our department between 1983 and 1998. Their ages ranged from 49 to 84 years, with a mean age of 65. One case showed the amelanotic type histologically. These cases were classified according to the criteria of the National Institute of Health. Five and 3 cases were stage I and stage III, respectively. All cases were treated by combination therapy consisting of surgery, radiation, chemotherapy, immunotherapy and hormonal therapy. Four cases survived for 2 years and 2 cases more than 5 years.

The possible roles of several hormones such as aldosterone, vasopressin, atrial natriuretic peptide (ANP) and catecholamines in the inner ear are reviewed on the basis of recent research results, including our data. The presence of a mineralocorticoid type I receptor, Na-K ATPase and amiloride-sensitive Na+ channels in the cells involved in the secretion and absorption of endolymph, such as the marginal cells, suggest that aldosterone may control endolymph secretion and absorption. The involvement of vasopressin in the homeostasis of the endolymphatic system, which has been suggested by several lines of evidence, remains to be clarified. Recent results have also suggested that ANP may control the secretion and absorption of endolymph in the inner ear, regulate cochlear nerve function, and control inner ear blood flow. Finally, recent evidence also suggests that catecholamines may regulate the function of the endolymphatic sac.

Thirty-one patients with chronic sinusitis were treated with 150 mg of roxithromycin (RXM) per day for 12 weeks.The percentages of patients with an excellent or a good subjective response after 12 weeks of therapy were: 37.9% with reduced frequency of nose blowing, 37.9% with increased ease of nose blowing, 36.0% with reduced frequency of postnasal drip, 36.0% with easier removal of postnasal drip, 45.9% with less nasal obstruction, 40.0% with less headache, 45.5% with improved sense of smell.Objective findings were reduced as follows: redness of the nasal mucosa in 31.8%, edema of the nasal mucosa in 34.4%, quantity of the nasal discharge in 48.3%. The quality of the nasal discharge was improved in 48.3%, and the X-ray findings in the maxillary sinus (36 sides) were improved in 11.1%, and in the ethmoid sinus (38 sides) in 10.5%.The percentages of patients improved after 4, 8, and 12 weeks of therapy were not significantly different.No side effects of RXM were noted during this investigation.

The results of tympanoplasty performed in 72 ears with cholesteatoma from 1988 to 1992 are analyzed. The patients were followed for 6 to 60 months (average 21.4 months). The canal down method was used in 32 ears, the canal up method in 8 ears, and posterior wall reconstruction in 32 ears. Mastoid obliteration was done in 61 ears. Staged and second look operations were performed in 19 and 14 ears, respectively. Fifteen of the 33 ears with staged or second look operations had residual cholesteatoma. Recurrence was observed in one ear treated with the canal up method and in 3 ears treated with posterior wall reconstruction. No recurrence was observed in ears treated with the canal down method. Tympanoplasty type I, type II, type II, columella type III, columella type IV were performed in 8, 1, 1, 48 and 14 ears, respectively. Autologous cartilage from the auricle was used in most ears as a columella. The rate of success of hearing preservation was 82% according to the Criteria of the Japan otological Society. There was no large difference in the rate of success of hearing preservation among the ears treated with the canal down method, canal up method and posterior wall reconstruction.

The results of long-term middle ear ventilation with a Koken tube (wide flange, A type) were retrospectively analyzed chiefly with respect to complications in 43 ears with otitis media with effusion in children aged 3 to 9 years. The average intubation period was 11 months.The average pure tone air conduction threshold showed remarkable improvement from 34.5 dBHL to 15.9 dBHL. Otorrhea, extrusion and obstruction of the tube were observed in 8 ears (18.6%), 9 ears (20.9%) and 3 ears (7.0%), respectively. No cholesteatoma or granuloma were seen. The ear drum perforation failed to close in 4 of 36 ears (11.1%) followed for more than 6 months after extrusion or removal of the tubes. Scarring of the ear drum was observed in 4 ears (12.5%). Recurrence of otitis media with effusion was seen in 15 of 32 ears (46.9%), in which the ear drum perforation was closed after extrusion or removal of the tubes.The present results indicate that the Koken tube (A type) is one of the best tubes for long-term middle ear ventilation.

During the past 3 years in a section providing hearing aid service in our hospital, 266 outpatients have been examined and fitting with hearing aids.We analysed their background factor: age, occupation, diagnosis, complications, hearing level, speech discrimination, use of hearing aids.Most patients were 50 to 70 years old, their hearing levels were 40-70dB and speech discrimination scores were more than 50% in the hearing aided ears. Their hearing levels varied widely, but speech discrimination scores were generally low, and many scores were less than 10% in unaided ears.We classified the patients' audiograms into eight types: flat, gradual, mountain, valley, dip, high cut, low deaf, profound type. On the aided side, many ears were gradual type and flat type; the unaided side tended to have the same type.The main situations in which many patients had trouble were “at meetings or conferences”, “always”, “in the house, watching television, using the telephone”, etc.We must always consider the patients' backgrounds and individual differences and we put the hearing aids to practical use.

The serum and middle ear tissue concentration of enoxacin, a pyridone carboxylic acid derivative, was measured in 20 patients with chronic otitis media. The drug was given orally in a dose of 600mg 3 times a day for one to 24 days (average 6.3 days) on an average of 13.1 hours before the serum and tissue samples were obtained during tympanoplasty. In the 14 patients, for whom data of both serum and tissue concentrations were obtained, the concentrations were 0.90±0.66μg/ml and 3.32±3.50μg/kg, respectively. The tissue concentration was 384±236% times the serum concentration.

The effect of lysozyme (Leftose°) on bleeding during tonsillectomy and adenoidectomy was investigated in children. Leftose° was administered for one week before and two weeks after the operation in 31 of 60 patients in whom tonsillectomy or adenotonsillectomy was performed.1) The blood loss during surgery was not significantly different between Leftose°-treated patients and the others.2) Blood coagulation tests before and after Leftose° administration showed no significant difference, but the bleeding time and partial prothrombine time decreased slightly in administration of Leftose°.3) No side effects of Leftose° administration were noted.Leftose° had no major effect on bleeding during tonsillectomy and adenoidectomy although it had a slight influence on blood coagulation.

Electrocochleographic changes accompanying fluctuations in hearing loss on 4 patients with Meniere's disease were reported. Extratympanic electrocochleography (ECochG) was performed again after the audiogram had changed at one or more frequencies. The intervals between these ECochGs ranged from 1 month to 2 years. In two patients whose audiogram had changed only at one frequency, no significant change in ECochG was found. In two patients whose audiogram had changed at three frequencies, changes in action potential (AP) thresholds corresponded to changes in the audiograms. Negative summating potential (-SP) detection thresholds and -SP amplitudes remained unchanged, but -SP/AP ratios were significantly changed. In one of two patients with significant changes in ECochG N1 latency was prolonged accompanying progression of the hearing loss. The mechanism causing changes in ECochG accompanying fluctuations in hearing loss was discussed.

22 patients presenting unmistakable symptoms of Meniere's disease including two bilateral cases, among whom a glycerol test and an electrocochleography were carried out on 24 ears. 13 out of 24 cases, i. e. 54%, turned out positive to the glycerol test, and 17 out of 24 cases, i. e. 71%, gave 0.5 or more in the electrocochleography's -SP/AP. Among those who were tested in a period close to a vertigo attack, the positive ratio was slightly higher in both tests: the former being 60% and the latter 84%. However, no correlation was observed between the results.When positive and negative groups are compared in the glycerol test results, in the positive group the majority showed large values in the -SP/AP in the vicinity of 1.0; while in the negative group, many showed fairly small values contained between 0.5 and 0.8.Based upon these results, we presume that an active endolymphatic hydrops is reflected by large -SP/AP in the vicinity of 1.0, and the increase of these specially large -SP/AP may turn out to be as significant as the positive group in the glycerol test.

A case of bilateral Meniere's disease was investigated by extratympanic electrocochleography both during a period of impaired hearing and during a period of fairly good hearing.After a vertiginous attack, conventional audiometry showed progression of the hearing loss in the right ear, while the hearing loss in the left ear remained unchanged.In the right ear, the significant changes in electrocochleographic findings after the attack were elevation of the AP response shreshold, the prolongation of N1 latency, and an increase in the SP/AP ratio.In the left ear, N1 latency had been prolonged, the AP waveform was broad, no SP component was detected, and there were no significant changes in the electrocochleographic findings.Clinical evaluations of changes in the electrocochleographic findings after a vertiginous attack were discussed.

Vertigo is closely related not only with central nerve disorders but with peripheral, circulatory and autonomous nerve disorders and such general disorders. We, therefore, conducted hematological examinations and hemadynamometric measurement at the time of change of bodily position on patients of vertigo in order to see if the hematological and hemadynamometric factors can be predispositions for vertigo. The subjects were the patients with established diagnosis of Meniere's disease, or suspected of Meniere's disease, or had vertigo accompanying cerebro-circulatory disturbances, or of vertigo unknown origin who visited Nara Prefectural Medical College's Otolaryngological Department in the period covering April 1978 through October 1979. For control, normal individuals and patients of sensorineural deafness were selected. The results of the above tests were compared between the group of vertigo and the group of having no vertigo, and the possible predispositions were compared between the time having vertigo and the time not having vertigo in order to determine if those could be factors for causing the disease. The results were as follows.1. Of all the items of hematological examination, total cholesterol, neutral fats, free fatty acids could be considered as predispositions for vertigo particularly in the cases of cerebro-circulatory disturbances. It was also considered that total cholesterol, free fatty acids, HDL and blood platelet aggregation were possibly the factors to cause vertigo.2. In hemadynamometry, the fluctuations of the mean arterial pressure and of the pulse pressure at change of bodily position were great in the cases of Meniere's disease while those in the cases of cerebro-circulatory disorders were small. Also in the patients having vertigo, decline of pulse pressure and differences of mean arterial blood pressure and pulse pressure between the right and left were observed. However, the hemadynamometric examination of this time did not differentiate critical factors of vertigo from predispositions.

Careful and complete removal of vascular tumors is challenging because of the brisk bleeding during operation. Preoperatively we used Gelfoam embolization of the feeding artery in juvenile angiofibroma and in paranasal capillary hemangioma. The intraoperative blood loss averaged 1045ml.Angiography is of value to confirm the diagnosis prior to excision and to delineate the extent of the tumor. Embolization may be performed at the same sitting as preoperative treatment. Artificial embolization is described in detail, and preoperative embolization is recommended to make the surgical procedure easier in cases of vascular tumor.