Published papers

In Japan, there is a government-mandated financial support system to help hearing-handicapped patients. In this welfare law, patients with severe hearing loss are categorized into three grades according to severity of hearing disturbance. Patients in each grade have the right to obtain financial support. Obtaining financial aid is a two-step process. First, the patient must apply for a certificate or license indicating that he/she is indeed hearing handicapped. It usually takes a few weeks to receive this license. Second, the patient must complete a financial support application form, which takes about one month for government approval. A doctor must sign both of these application forms. Between January 2005 and April 2006, we surveyed patients consulting our office for hearing aid counseling to assess the current situation and satisfaction of patients who bought hearing aids using governmental financial support. The patients graded their experience on a 5-point satisfaction scale. Among the eighty-nine patients who consulted our office, 22 (24.7%) patients applied for support; all 22 of these patients qualified as having a severe hearing-handicap. The average ages of patients certified as hearing handicapped and patients not certified as hearing handicapped were 80.9±7.7 years and 75.1±23.3 years, respectively. It took, on average, another 49 days to obtain financial support. Patients receiving governmental financial support rated their satisfaction significantly higher than did patients who did not receive support. The average amount of financial support was 40,736 yen ($340). A small amount of financial support can increase patient satisfaction. To promote the government-mandated financial support system for the hearing handicapped, doctors should show more interest in this law. Doctors should also actively guide and encourage certified patients in applying for governmental financial support for hearing aids, all with long-term goal of helping these patients achieve a better quality of life.

Conclusion: Lateral canal plugging with endolymphatic sac decompression (LCPESD) is a new therapeutic approach to intractable Meniere's disease. Further clinical data will be required. Objective: The objective of this paper is to present a new surgical procedure, i.e. lateral canal plugging (LCP) with endolymphatic sac decompression (ESD), which we defined as LCPESD. Two cases of intractable Meniere's disease, a 48-year-old male and a 48-year-old female, were successfully treated by this method. Methods: LCPESD was performed under general anesthesia. First ESD was undertaken followed by LCP. The bone was drilled up to the 'blue line' in the central portion of the bony lateral canal; then a 2 mm segment of canal was skeletonized to create a fenestra. A plug comprising temporalis fascia, bone pate, and fibrinogen glue was inserted through the fenestra to compress the endosteum and membranous labyrinth. Results: The attack of Meniere's disease was completely controlled and the hearing threshold did not change after the surgery for 2 years. Obliteration of the horizontal canal was confirmed by MRI.

Background The surgical approaches for clival chordomas remain controversial, although the extent of resection is one of the most important factors for long survival rates. Recently an endoscopic endonasal approach in good collaboration with otolaryngologists has attracted major attention as a surgical approach for clival chordomas. We describe our experience with the endoscopic endonasal approach and provide a review of the literature. Methods Between 2008 and 2011, six operations were performed via the endoscopic endonasal approach for clivus chordomas. The mean tumor size was 35 mm in diameter. The tumor location was mainly from the upper to middle clivus. The tumor extended into the cavernous sinus in five cases and intradurally in three cases. A binostril approach was performed in four cases, while a one nostril approach was performed in two cases. Results Gross total removal was achieved in three cases. The analysis of cases with incomplete resection suggested that residual tumors were observed epidurally and subdurally. The residual on the epidura was observed from the posterior clinoid to the posterior compartment of the cavernous sinus. On the other hand, the residual on the subdural was observed behind the upper part of the pituitary gland. There was no postoperative cerebrospinal fluid (CSF) leakage using vascularized nasoseptal flaps in any of the cases. Conclusions The endoscopic endonasal transclival approach allows an appropriate extent of resection with acceptable complication rates in comparison with other approaches. In our series, the accomplishment of gross total removal was associated with the relationship between the tumors and surrounding structures, such as the pituitary gland and the cavernous portion of the intracranial carotid artery (ICA).

Objectives: Intratympanic injection (ITI) of drugs into the inner ear is an attractive way to deliver therapy. However, if the round window membrane (RWM) cannot be visualized, adhesions need to be removed first before ITI can be performed. We developed and tested a novel otoendoscopy device that allows visualization of the RWM for the purpose of ITI. Methods: Our otoendoscope consists of a catheter channel for delivering drugs and a suction channel. Results: The novel otoendoscope for inner ear drug delivery has a fine needle with catheter, which can be used to remove or perforate round window niche (RWN) mucosal adhesions. The elliptical shape of the otoendoscope effectively captures the field in the light-guided area, resulting in bright images. Conclusions: Our otoendoscope can be used to apply drugs directly onto the surface of the RWM and to verify the correct placement of an inner ear drug delivery system, ensuring that it is safely in place.

Background: Patients with clinical stage I/II (T1-2N0M0) oral tongue squamous cell carcinoma (TSCC) usually undergo partial glossectomy alone. However, 14-48% of them develop delayed neck metastasis (DNM), which may lead to an unfavorable course. Recently epithelial-to-mesenchymal transition (EMT) has been thought to play a crucial role in cancer metastasis. The present study aimed to examine the associations of EMT-involved molecular factors and clinicopathological factors with DNM in stage I/II TSCC. Methods: mRNA expression levels of E-cadherin and its transcriptional repressors (snail, SIP1, and twist) in 7 head and neck squamous cell carcinoma (HNSCC) cell lines were evaluated by quantitative real-time PCR. Clinicopathological parameters and immunohistochemical expressions of E-cadherin and its repressors were examined in surgical specimens of 37 stage I/II TSCC patients who underwent partial glossectomy alone. Results: In HNSCC cells, E-cadherin expression was inversely correlated with SIP1 expression (P = 0.023). Univariate analysis of immunohistochemistry showed that overexpression of SIP1 and loss of E-cadherin were significantly correlated with DNM, although no inverse correlation was found between E-cadherin and its repressors. Multiple logistic regression analysis including clinicopathological and molecular factors revealed that overexpression of SIP1 (P = 0.005), loss of E-cadherin (P = 0.046), and vascular invasion (P = 0.024) were independently correlated with DNM. Conclusions: These results suggest that development of DNM in stage I/II TSCC is closely related to induction of EMT in primary tumor cells. Especially, SIP1 and E-cadherin are considered to be the possible markers for selecting patients at high risk of DNM.

Objective: Thus far, no objective measure has been developed to evaluate tinnitus severity. There is a close relationship between tinnitus and depression, in which brain-derived neurotrophic factor (BDNF) has a pathophysiological role. To determine whether BDNF levels could be used to evaluate tinnitus severity, we evaluated plasma BDNF levels in patients with tinnitus. Methods: Plasma BDNF levels were measured in 43 tinnitus patients and 30 healthy control patients. The severities of tinnitus, depression, and anxiety were measured using the tinnitus handicap inventory (THI) and the hospital anxiety and depression scale (HADS), respectively. Patients with tinnitus were divided into 2 groups depending on their THI scores: mildly handicapped (<36) and severely handicapped (>38). We also divided our subjects into 2 groups depending on the HADS score, which represents patient mood, including depression and anxiety. Results: Plasma BDNF levels were significantly higher in the mildly handicapped group than in the severely handicapped and control groups (P< 0.01). Patients with HADS scores of ≤14 had significantly lower THI scores (P< 0.05) and higher BDNF levels (P< 0.01). Conclusions: Our findings show for the first time that plasma BDNF levels vary with the severity of tinnitus, suggesting that plasma BDNF level is a useful tool for objective evaluation of tinnitus.

In this study, a three-dimensional finite-element model of the passive human cochlea was created. Dynamic behavior of the basilar membrane caused by the vibration of the stapes footplate was analyzed considering a fluid-structure interaction with the cochlear fluid. Next, the effects of a perilymphatic fistula (PLF) on the vibration of the cochlea were examined by making a small hole on the wall of the cochlea model. Even if a PLF existed in the scala vestibuli, a traveling wave was generated on the basilar membrane. When a PLF existed at the basal end of the cochlea, the shape of the traveling wave envelope showed no remarkable change, but the maximum amplitude became smaller at the entire frequency range from 0.5 to 5. kHz and decreased with decreasing frequency. In contrast, when a PLF existed at the second turn of the cochlea, the traveling wave envelope showed a notch at the position of the PLF and the maximum amplitude also became smaller. This model assists in elucidating the mechanisms of hearing loss due to a PLF from the view of dynamics.

There are some patients complaining of somatic symptom who has depression. The use of antidepressant to these patients would be quite useful. Patients with dispersion have a variety sort of physical symptom. The evaluation of depression based on physical complaints may be difficult for otorhinolaryngologists, but it is important to do so where possible to increase the focus on the subject's physical illness. The prevalence of somatic complaints in hospitalized patients whose chief complaint was either dizziness or vertigo was very high. These patients were usually accompanied with depression. Then the effect of paroxetine to the patients with tinnitus was investigated. The paroxetine may be effective in treating distressed tinnitus patients with depression and anxiety by reducing their tinnitus severity as well as their depression and anxiety.

We reviewed 86 patients with oral tongue squamous cell carcinoma who were initially treated with curative intent in the Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine between 1996 and 2007. Statistical analysis was performed to examine the prognostic value of the clinical features. Eighty patients underwent surgery and six underwent radiotherapy as the initial treatment. The five-year disease-free survival (DFS) rates determined by the Kaplan-Meier method were as follows: 75.8% in all stages, 88.7% in stage I (n = 30), 82.6% in stage II (n = 24), 77.1% in stage III (n = 14), and 39.7% in stage IV (n = 18). Univariate analysis demonstrated that stage III/IV, T 3/4, and N2 were significantly correlated with poor prognosis, whereas multivariate analysis showed that only N2 was independently correlated with poor prognosis. Neoadjuvant chemotherapy (NAC) was applied for 24 patients. Although the DFS of the responders (CR+PR) was higher than that of the non-responders (NC+PD), the difference was not significant. Among 80 patients who received surgical treatment initially, neck dissection (ND) was performed in 42 patients. Five-year DFS was significantly higher in the patients with no or single node metastasis than in the patients with multiple node metastases (93.8% vs. 32.7%). These outcomes suggest that more aggressive postoperative therapy should be recommended for patients found to have pathologically multiple positive nodes.

Abstract. Introduction. Radionecrosis (post-radiotherapy laryngeal submucosal inflammation and necrosis) is a complication of (chemo) radiotherapy for hypopharyngeal cancer that is difficult to differentiate from tumor recurrence. Case presentation. A 67-year-old Japanese man presented with a condition extremely difficult to diagnose differentially as radionecrosis or tumor recurrence after radiotherapy for hypopharyngeal cancer. Although tumor recurrence was suspected from clinical conditions and computed tomography findings, pathologic analysis revealed no evidence of tumor recurrence, and successful therapy with steroids and antibiotics reduced the mucosal edema. Conclusion: Our findings emphasize the wide spectrum of radiographic presentation of radionecrosis after chemoradiation of stage IV hypopharyngeal cancer.

Objective: Vestibular rehabilitation strategies mostly require a long-lasting training in stance conditions, which is finally not always successful. The individualized training in everyday-life conditions with an intuitive tactile neurofeedback stimulus seems to be a more promising approach. Hence, the present study was aimed at investigating the efficacy of a new vibrotactile neurofeedback system for vestibular rehabilitation. Study Design: Double-blinded trial. Patients: One hundred five patients who experience one of the following balance disorders for more than 12 months were included in the study: canal paresis, otolith disorder, removal of an acoustic neuroma, microvascular compression syndrome, Parkinson's disease, and presbyvertigo. Interventions: Vibrotactile neurofeedback training was performed daily (15 min) over 2 weeks with the Vertiguard system in those 6 tasks of the Standard Balance Deficit Test with the most prominent deviations from the normative values. Main Outcome Measures Trunk and ankle sway, dizziness handicap inventory, and vestibular symptom score were measured in the verum and placebo group before the training, on the last training day and 3 months later. Results: A significant reduction in trunk and ankle sway as well as in the subjective symptom scores were observed in the verum group. Such an effect could not be found in any of the outcome parameters of the placebo group. Conclusion: The vibrotactile neurofeedback training applied in the present study is a highly efficient method for the reduction of body sway in different balance disorders. Because the rehabilitation program is easy to perform, not exhausting, and time saving, elderly patients and those with serious, long-lasting balance problems also can participate successfully.

Background: Combining ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI) and fine-needle aspiration cytology (FNAC) usually results in the best preoperative diagnosis of cervical masses, including neoplasms. This may not be tnie, however, especially in occult papillary thyroid carcinoma (PTC) associated with single cystic cervical lymph node metastasis. We assessed the role of thyroglobulin measurement in FNA fluid (FNATg) in differentially diagnosing cystic cervical mass lesions, including PTC cystic lymph node metastasis. Methods: We reviewed the records of 17 subjects with cervical cystic masses undergoing both FNATg measure ment and surgery. FNA was done under ultrasonographic guidance. We also measured FNATg concentrations from extrathyroid lesions, consisting of cystic cervical lymph node metastases and benign cystic lesions. Results: Pathological diagnosis involved 5 PTC lymph node metastases, 3 lateral cervical cysts, 7 thyroglossal duct cysts, and 2 squamous cell carcinoma (lung and oropharynx) lymph node metastases. FNATg of PTC lymph node metastasis was much higher than the reference range of blood serum thyroglobulin, although much lower for the lateral cervical cyst detection threshold. FNAC and FNATg measurement are thought to be mutually complementary in the differential-diagnosis of PTC cystic lymph node metastasis. Conclusion : High concentrations of FNATg in a cystic cervical mass is considered specific to PTC lymph node metastasis, indicating its usefulness in distinguish PTC cystic metastasis from other cystic lesions. Including FNATg measurement with FNAC may thus improve preoperative diagnosis accuracy without additionally stressing subjects with PTC cystic lymph node metastasis.

Data are limited on the role of psychotherapy in the treatment of Ménière disease. We sought to document the effect of a psychotherapeutic technique known as autogenic training on clinical outcome in Ménière disease. Six patients with Ménière disease were studied. Retrospective chart review was conducted. All patients were refractory to conventional therapy and completed a course of autogenic training, which was offered as a complementary treatment. Autogenic training with initial psychological counseling was conducted by a clinical psychologist during 45-min sessions. Outcome measures assessed were the frequency of vertigo and functional levels 2 years after initiation of autogenic training. Functional levels were evaluated according to the 1995 guidelines of the American Academy of Otolaryngology-Head Neck Surgery (AAO-HNS). As a personality measure, we used the Maudsley Personality Inventory (MPI), devised by Eysenck, which measures neuroticism (N), extraversion (E), and propensity to lie (L). Five of six patients showed improved functional level after three to eight sessions of psychotherapy; hearing level did not change. The score of the N scale of the MPI was closely related to the number of psychotherapy sessions. Prognosis was evaluated based on the AAO-HNS reporting guidelines, as follows: A = 3, B = 1, C = 1, F = 1. The value of N in MPI was closely related to the number of psychological counseling sessions (R = 0.97, P < 0.05). In conclusion, autogenic training may enhance the mental well-being of patients with Ménière disease and improve clinical outcome.

We previously reported a model of acute cochlear energy failure using a mitochondrial toxin, 3-nitropropionic acid (3-NP), to study mechanisms of inner ear disorders such as inner ear ischemia. In this model, the main cause of hearing loss is apoptosis of fibrocytes in the cochlear lateral wall. Here, we analyzed the time course of structural and hearing level changes in the cochlea from the acute phase to the chronic phase up to 2 months after surgery. Hearing levels as determined by auditory brainstem response (ABR) thresholds exceeded the maximum acoustic output (> 87 dBSPL) of the system at all frequencies 1 day after 3-NP treatment. Histology showed nearly complete loss of fibrocytes 2 weeks after 3-NP treatment. However, after 2 months, ABR showed significant recovery at low frequency (8 kHz) in four of five rats treated with 3-NP. ABR thresholds at 20 kHz occasionally showed some recovery. At 40 kHz, recovery of ABR thresholds was not observed. Histology of 3-NP-treated rats revealed partial recovery of the lateral wall and the regenerated fibrocytes in the spiral ligament expressed Na/K-ATPase in the cochlear basal turn 2 months after 3-NP treatment. These results indicate that ABR recovery is caused by regeneration of the cochlear lateral wall. Our findings demonstrate the recoverable capacity of the cochlear lateral wall that leads to functional recovery after severe damage.

Therapeutic options for vertigo may be pharmacological or non pharmacological. Intractable dizziness may require conventional drug therapy or vestibular exercises. We set up a single-group outpatient vestibular exercise course and evaluated its benefit. Subjects numbered 18 having chronic vertigo whose etiology included unilateral canal paresis following vestibular neuritis. Time from disease onset to the introduction of vestibular exercise was from 6 to 70 months (average ±std: 22.1±21.1). Small-groups home-based vestibular exercise consisted of a 2-hour lecture and practice in which subjects were taught exercises to be done 4 times a day at home. Symptoms of vertigo were obtained using Japanese version of the dizziness handicap inventory (DHI) and static posturography at the initial visit and before, 2 months, and 4 months after rehabilitation. The DHI score at the initial visit was 38. 6 ±26. 0 compared to 12. 3 ±10. 2 4 months after rehabilitation. The static posturography area did not change before or after therapy. We recommend that future studies objectively assess how the DHI score could be improved.

Non-Hodgkin diffuse large B-cell lymphomas of the mastoid that extend from the nasopharynx are extremely rare in children. Moreover, in lymphoproliferative diseases, the presence of otoneurological signs prior to systemic disease involvement is rare. Here, we present a rare case of non-Hodgkin B-cell lymphoma invading the middle ear and mastoid in a 1-year-old boy that mimicked acute mastoiditis with complete facial nerve palsy. As this case illustrates, physicians should consider a diagnosis of malignant lymphoma if a patient presents with otitis media and mastoiditis accompanied by facial palsy.

Conclusion: The Japanese version of the Dizziness Handicap Inventory (DHI) is a reliable, comprehensively validated, and clinically useful tool to measure self-perceived handicap associated with dizziness. Objectives: The DHI is a useful instrument to document the consequences of vestibular and/or balance impairment. A Japanese version of this self-assessment inventory is needed to evaluate the handicapping effects imposed by vestibular system disease in Japanese patients. The purpose of this study was to determine the internal consistency of the reliability of the Japanese version of the DHI. Methods: We recruited 176 patients between January and September 2008 from the outpatients of the Department of Otolaryngology, Hino Municipal Hospital, Japan. The DHI was translated into Japanese, and the test was independently completed by each subject. We used principal component analysis to evaluate the different dimensions of the DHI. The internal consistency of the retained factors was investigated by estimating Cronbach's alpha coefficients and corrected item-total correlations. Results: Cronbach's coefficients for internal consistency were high for the total scale (0.93) and good for the subscales: functional subscale (0.87), physical subscale (0.82), and emotional subscale (0.85). The correlation matrix demonstrated that the variables were suited for factor analysis. The determinant was 1.26E 6, which is slightly under the recommended value. Bartlett's test was highly significant (p < 0.0001), and the KaiserMeyerOlkin measure of sampling adequacy was 0.91.

Objective: To assess factors that contribute to Tinnitus Handicap Inventory (THI) scores in Japan. Design: Case series with chart review. Study sample: Two hundred and eighty-five tinnitus patients at tertiary referral center, who completed the Japanese version of the THI, the Self-rating Depression Scale (SDS), and the State Trait Anxiety Inventory (STAI). Results: In multiple regression analysis, the SDS score contributed the most to the THI score. The state section of the STAI score and pure tone average (PTA) at four high frequencies also contributed significantly, but to lesser degrees. The other following factors were not statistically significant: age, gender, time from the onset of tinnitus to the first clinical visit, PTA at three mid frequencies, and trait section of the STAI score. This model may account for approximately 45% of THI score variability. Conclusions: The THI scores may be influenced by depressive symptoms, state anxiety, and pure tone thresholds in Japan.

The development of the inner ear is an orchestrated process of morphogenesis with spatiotemporally controlled generations of individual cell types. Recent studies have revealed that the Sox gene family, a family of evolutionarily conserved HMG-type transcriptional factors, is differentially expressed in each cell type of the mammalian inner ear and plays critical roles in cell-fate determination during development. In this study, we examined the expression pattern of Sox21 in the developing and adult murine cochlea. Sox21 was expressed throughout the sensory epithelium in the early otocyst stage but became restricted to supporting cells during adulthood. Interestingly, the expression in adults was restricted to the inner phalangeal, inner border, and Deiters' cells: all of these cells are in direct contact with hair cells. Evaluations of the auditory brainstem-response revealed that Sox21-/- mice suffered mild hearing impairments, with an increase in hair cells that miss their appropriate planar cell polarity. Taken together with the previously reported critical roles of SoxB1 families in the morphogenesis of inner ear sensory and neuronal cells, our results suggest that Sox21, a counteracting partner of the SoxB1 family, controls fine-tuned cell fate decisions. Also, the characteristic expression pattern may be useful for labelling a particular subset of supporting cells.