Substance P and Calcitonin Gene-Related Peptide in the Glands of External Auditory Canal Skin

OBJECTIVES: The earwax (cerumen) that covers external auditory canal (EAC) skin contains a mixture of ceruminous and sebaceous gland substances, such as lipids, peptides, and proteins. The components secreted from the ceruminous gland that is a modified sweat gland form cerumen and contain several antimicrobial factors. Since substance P (SP) and calcitonin gene-related peptide (CGRP), known as a secretagogue, have been found in sweat glands, our purpose was to determine the expression of SP and CGRP in the glands of EAC skin. METHODS: Sections of normal human EAC skins were immunostained for the presence of SP and CGRP using polyclonal antibodies. Immunoreactivity was detected using an avidin-biotin peroxidase complex method. RESULTS: SP staining was found in ceruminous gland acini and myoepithelial cells. But the SP staining was not found in the sebaceous glands and epidermal region. CGRP was strongly stained in the ceruminous gland and weakly in the sebaceous gland cells. Interestingly, most prominent staining of SP and CGRP was noted in the myoepithelial cells of the ceruminous gland. CONCLUSION: The findings in this study suggest that SP and CGRP are expressed in the glands of the EAC skin and secreted in the process of ceruminous gland secretion.

Comparison of Arbekacin and Vancomycin in Treatment of Chronic Suppurative Otitis Media by Methicillin Resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of ear infections. We attempted to evaluate the clinical usefulness of arbekacin in treating chronic suppurative otitis media (CSOM) by comparing its clinical efficacy and toxicity with those of vancomycin. Efficacy was classified according to bacterial elimination or bacteriologic failure and improved or failed clinical efficacy response. Ninety-five subjects were diagnosed with CSOM caused by MRSA. Twenty of these subjects were treated with arbekacin, and 36 with vancomycin. The bacteriological efficacy (bacterial elimination, arbekacin vs. vancomycin: 85.0% vs. 97.2%) and improved clinical efficacy (arbekacin vs. vancomycin; 90.0% vs. 97.2%) were not different between the two groups. However, the rate of complications was higher in the vancomycin group (33.3%) than in the arbekacin group (5.0%) (P=0.020). In addition, a total of 12 adverse reactions were observed in the vancomycin group; two for hepatotoxicity, one for nephrotoxicity, eight for leukopenia, two for skin rash, and one for drug fever. It is suggested that arbekacin be a good alternative drug to vancomycin in treatment of CSOM caused by MRSA.

Otologic and Audiologic Characteristics in Children with Turner Syndrome / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Turner syndrome (TS) is known to be caused by a total or partial deletion of one X-chromosome. Besides short stature and failure to enter puberty due to ovarian dysgenesis, auricular malformations, middle ear diseases and hearing impairment are also other clinical features of Turner syndrome. The goal of this study is to report otologic and audiologic characteristics in a group of children with Turner syndrome and correlate with these findings to karyotype. SUBJECTS AND METHOD: We retrospectively reviewed the outpatient charts of those who visited at our department for otologic and audiologic screening test between 2008 and 2011. All 23 TS children (46 ears) were enrolled under regular control of their pediatric endocrinologist for treatment with growth hormon and Estrogen. The mean age was 12.6 years (6-24 years). All children were evaluated by otologic history taking, otoscopy, pure tone audiometry and karyotyping. Furthermore, 16 children undertook auditory brain stem response (ABR) test and 10 children temporal bone computed tomography (CT). RESULTS: Abnormal otoscopic findings were found in 48% (22 ears), abnormal otologic history in 70% (16 children), and abnormal audiologic findings in 70% (32 ears). According to karyotyping, the total p-arm deletion group (74%) showed unfavorable audiologic results. ABR test and temporal bone CT did not show any unique findings, except five poor pneumatization of mastoid. CONCLUSION: Hearing impairment can be present at early age in Turner syndrome. Careful follow up during childhood is necessary to detect early ear and hearing problems for active intervention. Karyotype may be used as a predictor for future hearing impairment.

A Case of Delayed Spontaneous Aneurismal Rupture after Ear Surgery Under General Anesthesia

Many complications have been reported after ear surgery to treat chronic inflammation. These complications include facial nerve paralysis, perichondritis, injury of the dura or of the sigmoid sinus, cyst formation or mucocele in the healed mastoid cavity, and the recurrence of cholesteatoma, granulation tissue, or otorrhea. It might be believed that there could be no relation between ear surgery and spontaneous aneurysmal rupture, and only one other case of spontaneous aneurysmal rupture after ear surgery under general anesthesia has been previously reported in Korea. However, recently, the authors encountered a case of delayed spontaneous aneurysmal rupture 3 weeks after surgery. No problem was experienced during the operation, and it is suspected that an unidentified pre-existing aneurysm was responsible for the intracerebral hemorrhage.

The Distributional Characteristics of Mast Cells in the Skin of the Human External Auditory Canal / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES : Mast cells are abundant at environmental barrier sites enabling quick reactions to any harmful events. Host defense in the skin may be occupied by the secretions from gland cells of the external ear canal skin. The aim of this study was to localize mast cells in the canal skin and compare it with that found in the ceruminous and sebaceous glands. MATERIALS AND METHOD : The distribution of mast cells (tryptase, chymase) in the external auditory canal skin of the human was observed histologically by means of immunostaining with ABC complex method after fixation with 4% paraformaldehyde solution. RESULTS : Mast cells were confined mainly to a dermal layer just beneath the outer layer of keratinizing stratified squamous epithelium. The mast cells also distribute densely in the deeper layer of the dermis of the canal skin more than in the superficial layer. Most of the mast cells were found adjacent to ceruminous glands though some lay scattered in the region of sebaceous glands. CONCLUSION : These findings of increased mast cell localization in the deep dermis rather than in the superficial dermis, as well as their concentration around the ceruminous glands, raise the possibility of an interaction between glands and mast cells.

Prognostic Factors of Acute Acoustic Trauma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The prognosis and prognostic factors for acute acoustic trauma are difficult to predict. The aim of this study was to assess the prognostic factors of acute acoustic trauma. SUBJECTS AND METHOD: The cases selected for this report are 27 patients with acute acoustic trauma and 139 patients with sudden deafness are selected for control group. The following factors were examined for prognostic factors: age, vestibular symptom, degree of initial hearing loss, number of days before the start of treatment. RESULTS: Most strongly related factor for prognosis is number of days before the start of treatment, but other factors are not significant relation for prognosis. The overall hearing recovery rate of acute acoustic trauma was 29.6% and that of sudden deafness is 56.1%. CONCLUSION: Early treatment of acute acoustic trauma increases hearing recovery rate, and acute acoustic trauma has worse prognosis than sudden deafness.

A Case of Therapeutic Percutaneous Embolization of Spontaneous Arteriovenous Fistulas with Pulsatile Tinnitus Involving the Branches of the Left External Carotid Artery / 대한이비인후과학회지

Arteriovenous fistulas of head and neck, especially the external carotid artery are uncommon lesions usually of traumatic origin. They also may be spontaneous, inflammatory, or congenital origin. They maybe accompanied by symptoms and signs such as pulsatile tinnitus, pulsatile mass, palpable thrill, and machine like bruit. Recently, we experienced a case of spontaneous arteriovenous fistula of external carotid artery, treated by coil embolization. The patient noticed pulsatile tinnitus in the left posterior auricular area and left upper neck area. She had no history of head trauma. External carotid angiogram showed fistula between the branches of the external carotid artery (occipital artery, middle meningeal artery, posterior auricular artery) and the internal jugular vein. The fistulas were successfully controlled by coil embolization.

A Case of High Jugular Bulb Associated with Conductive Hearing Loss / 대한이비인후과학회지

A high jugular bulb is often discovered as an incidental finding that is asymptomatic. The incidence of high jugular bulb protruding into the level of oval window is rare. Conductive hearing loss in association with this anomaly may occur, but has been reported infrequently in the literature. We report one case of high jugular bulb and the associated conductive hearing loss. Mechanisms to explain the conductive hearing loss include contact of the jugular bulb with tympanic membrane, interference with the ossicular chain, and obstruction of the round and oval window niche. The operative findings, radiographic and audiometric data that support these mechanisms of couductive hearing loss are presented.

Immunohistochemical Localization of Alpha-Atrial Natriuretic Polypeptide in the Human Nasal Polyp

BACKGROUND AND OBJECTIVES: Alpha-atrial natriuretic polypeptide (ANP) is a peptide which is involved in the regulation of fluid and electrolyte homeostasis. The purpose of this study is to localize ANP in the human nasal polyps by immunoperoxidase and immunofluorescence methods. Materials and Methods: Polyps were obtained at routine polypectomy under local anesthesia, Sections were processed for immunocytochemical demonstration of ANP using the avidin -biotin -peroxidase complex (ABC) procedure and the FITC immunofluorescence technique. RESULTS: ANP was detected in the surface epithelium of nasal polyps. These apical cells stained deeply with ANP. In the stroma, ANP was confined to acinar cells in the mucosal glands. No immunoreaction was detected in either the goblet cells or the fibroblasts. CONCLUSION: The large number and wide spread distribution of ANP-immunoreactive cells in nasal polyps imply that ANP could be involved in their pathophysiology.

Pathophysiologic Consideration of Benign Paroxysmal Positional Vertigo due to the Horizontal Semicircular Canal Cupulolithiasis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular disorders. There have been some reports suggesting that directional changing positional nystagmus occurs due to canalolithiasis and cupulolithiasis of the horizontal semicircular canal (HC). The canalolithiasis theory of HC-BPPV is presented with a transient geotropic direction changing horizontal nystagmus as the pathophysiologic mechanism of BPPV. The HC-BPPV cupulolithiasis is characterized by a positional nystagmus that does not fatigue, but persists as long as the position is held, and changes direction in different head positions. There is still a controversy relating to differentiating the lesion side and the otolith adherent sites on the cupula differentiation. The purpose of this study was to differentiate the lesion side and the otolith adherent site on the cupula, and propose a treatment through analyses of clinical features, electronystagmographic (ENG) results, treatment maneuvers and its effectiveness. SUBJECTS AND METHOD: Fifteen patients who showed ageotropic direction changing horizontal nystagmus were included in this study. Supine head turning test was performed to induce positional nystagmus. Various findings of the nystagmus were recorded with ENG. Other ENG tests (visual tracking tests and bithermal caloric test) and magnetic resonance imaging were checked to exclude the possibility of any central lesion. Cupulolith repositioning maneuver (CuRM) was applied on the all patients and these patients were instructed to keep the healthy side at the lateral decubitus position while sleeping. RESULTS: All patients showed significant differences between the intensity of each side nystagmus, and all of them showed stronger ageotropic direction changing horizontal nystagmus when the head was rotated to the unaffected side in a supine head turning test. The nystagmus had a short latency, no fatigability, and persistency in character. Typical nystagmus and spinning sensation in the supine head turning test had completely subsided after physical therapy. CONCLUSION: In the cupulolithiasis of horizontal semicircular canal, ageotropic nystagmus was stronger when the pathological ear was at the uppermost position, and this excitatory nystagmus beats to the lesion side. The proposed CuRM and post-treatment lateral decubitus position kept during the night (while sleeping on the day of treatment) were effective in differentiating the otolith adherent site on the cupula and treating the cupulolithiasis of the horizontal semicircular canal.

A Case of Recurrent Facial Palsy with Severe Hypertension due to Dysplastic Kidney and Renal Artery Aneurysm / 대한이비인후과학회지

Facial paralysis was first described in a hypertensive patient by Moxon in 1869. Subsequently, there have been reports and facial palsy is mentioned as a rare feature of hypertension. Recently, we experienced a case of recurrent facial paralysis in a severe hypertensive child. A 13-month-old boy was admitted because of right peripheral facial paralysis. Two months ago, transarterial embolization of his left renal aneurysm with coils was performed due to left renal dysplasia and renal artery aneurysm. On admission, his blood pressure was 200/110 mmHg. He was treated conservatively with antihypertensive agents and his facial paralysis completely resolved during the next two months. One year later, he experienced facial paralysis again. He was admitted and treated with antihypertensive agents. And his paralysis resolved in the next two months. After his left nephrectomy, performed three years later, there was no additional episode of facial paralysis during the next seven years. We report this case with a brief review of literatures.

Ultrastructural Characteristics of the Round Window Membrane During Pneumococcal Otitis Media in Rat

To understand better the pathogenesis of inner ear (IE) damage caused by otitis media (OM), the round window membrane(RWM) structure was investigated in a rat model for pneumococcal otitis media (POM). The RWM of 25 rats were evaluated light and electron microscopically on 1 day, 3 days, 6 days, 10 days, and 20 days after the unilateral inoculation of type 3 pneumococcus suspension into their middle ear cavities. The thickness of the RWM increased in various stages of the pneumococcus-evoked otitis media, compared with that of the normal. The thickening was most pronounced on day 1, being about 4 to 5 times greater than that of the normal RWM. All layers of the RWM were affected by the pneumococcal infection, but the major changes were confined to the subepithelial space close to the basement membrane (BM). Together with alterations to the BM, the most distinct pathological features were characterized by an increase and hypertrophy of fibroblasts in association with abundant collagen fibers. Elastic fibers observed close to the inner mesothelial layer under a high power magnification also increased during the experiment. These results will be relevant to a better understanding of the histologic implication of RWM in stages of acute otitis media involving pneumococcus-evoked otitis media.

Distribution of Mast Cells in the Rat Tympanic Membrane and Eustachian Tube / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Mast cells are widely distributed in the loose connective tissue and their predilection sites are the portals of entry into the host. It seems possible that mast cells play an important role in the eustachian tube as a gate of the middle ear cavity. The purpose of this study was to investigate the distribution of mast cells in the rat tympanic membrane and eustachian tube. MATERIALS AND METHODS: The tympanic membrane and eustachian tube of rats (5) were used in this study. The specimens of formalin-fixed paraffin-embedded tissues (4 micrometer) were observed by staining with toluidine blue. RESULTS: In the tympanic membrane mast cells were observed mainly just beneath the keratinizing stratified squamous epithelium of the tympanic membrane. Mast cells were also distributed in the connective tissue of the eustachian tube. Most of the mast cells were found adjacent to vessels and glands. The density of mast cells beneath the mucosal epithelium of the eustachian tube was significantly lower than that in deep connective tissue layer. Their presence in the eustachian tube was less prominent than in the tympanic membrane. CONCLUSION: It seems reasonable to suggest that mast cells in the tympanic membrane and eustachian tube are important in responding to continuous stimuli of the tympanic cavity.

Benign Paroxysmal Positional Vertigo of the Horizontal Semicircular Canal / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Benign paroxysmal positional vertigo (BPPV) is the most common disease of the peripheral vestibular disorders. Canalithiasis theory of the posterior semicircular canal is widely accepted as the pathophysiologic mechanism of BPPV. Recently, some authors reported that geotropic direction-changing horizontal nystagmus is attributed to the BPPV of the horizontal semicircular canal. The purpose of this study is to aid in the understanding and diagnosis of this disease through the analysis of the clinical features and electronystagmographic (ENG) results. MATERIALS AND METHODS: Nine patients who showed geotropic direction-changing horizontal nystagmus were included in this study. Supine head turning test was performed to induce positional nystagmus. Various findings of the nystagmus were recorded with ENG. Other ENG tests (visual tracking tests and bithermal caloric test) and MRI (4 cases) were checked to exclude the possibility of the central origin. RESULTS: All patients showed geotropic direction-changing horizontal nystagmus in supine head turning test. The nystagmus had a short latency, no fatigabilily and long duration (>1 min). The nystagmus was more intense in diseased ear of down position and changed its direction spontaneously (secondary nystagmus) in 7 cases. CONCLUSION: All patients complaining of paroxysmal positional vertigo should undergo two positional tests: Dix-Hallpike test and supine head turning test. Characteristics of nystagmus can be explained by canalithiasis theory of the horizontal semicircular canal.

A Case of Teratoma of the Middle Ear / 대한이비인후과학회지

Teratomas are true tumours derived from the three germinal layers (ectoderm, mesoderm, endoderm) which differentiate into identifiable tissues and organs. Embryologically, they are thought to result from the displacement of pluripotent cells from normal tissue during embryogenesis. Teratomas commonly occur in the sacrococcygeal region, gonads and mediastinum, but teratoma of the middle ear is exceedingly rare. Treatment for teratomas of the middle ear should be early, complete surgical excision to prevent local destruction and although rare, malignant transformation. We present a case of middle ear teratoma with a review of the literature.

Immunohistochemical Localization of Alpha 1-antitrypsin in the Rat Eustachian Tube and Tympanic Membrane / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The major antielastase involved in preventing breakdown of elastic fiber in the airway is alpha 1-antitrypsin. In this regard, the eustachian tube may have the protease (elastase)-antiprotease (alpha 1-antitrypsin) system. MATERIALS AND METHODS: Sprague-Dawley rats were perfused with 4% paraformaldehyde. After fixation, the eustachian tube containing a part of middle ear was transfered to a 0.1 M EDTA solution, followed by embedding in paraffin wax. The avidin-biotin-peroxidase procedure was used to identify alpha 1-antitrypsin. RESULTS: The immunoreactivity for alpha 1-antrypsin in the eustachian tube appeared strongly in the cilia of pseudostratified columnar epithelium and serous cells of the submucous glands. In the tympanic membrane, it was distributed selectively in the inner mucosal epithelium. The strong immunostaining was also noticed in the glands of external auditory canal. CONCLUSION: We found that elastic fibers and alpha 1-antitrypsin in the eustachian tube and tympanic membrane may be interrelated to the maintenance of the normal function of the middle ear.

Two Cases of Intradermal Nevus of the External Auditory Canal / 대한이비인후과학회지

The intradermal nevus is composed of nevus cells which are usually referred to as the melanocytic nevi and is a form of benign cutaneous tumor. Although the intradermal nevi are common benign pigmented skin tumors, their occurrence within the external auditory canal is uncommon. The clinical and pathologic features of the intradermal nevus arising within the external auditory canal are presented, with a review of literature.

A Case of Subtentorial Subdural Empyema Resulting from Chronic Otitis Media with Cholesteatoma / 대한이비인후과학회지

The subdural empyema is a rare disease characterized by a collection of pus in the subdural space. It usually occurs as a complication of otolaryngologic infections such as paranasal sinusitis, otitis media or mastoiditis. Although pus may localize anywhere in the subdural space, more than 90% of cases occur supratentorially. Infratentorial subdural empyema is rare, most of them otogenic, but subtentorially localized empyema is even rarer. It is considered as a neurosurgical emergency, but some authors have reported successful treatment of subdural empyema with conservative treatment. We have experienced a case of subtentorial subdural empyema resuting from chronic otitis media with cholesteatoma which was successfully treated with mastoidectomy, accompanied by the conservative treatment. In this paper, we report this case with a review of literature.

Immunohistochemical Localization of Insulin-Like Growth Factor-I in the Eustachian Tube of the Rat / 대한이비인후과학회지

Insulin-like growth factor-I(IGF-I) is a peptide hormone of approximately 7.5 kilodaltons which has been shown to be involved in cellular growth and differentiation. Because the IGF-I is synthesized in a variety of tissues, it is thought to act both locally in a paracrine/autocrine manner, as well as a true endocrine hormone after entering the circulation. It may be considered that IGF-I is very important for differentiation of bone, cartilage, and muscle. The eustachian tube has the function of ventilation, clearance, and protection of the middle ear, contributing to the maintenance of normal hearing. After the opening of eustachian tube, it may return to its original position by elasticity resulting from the recoil of elastic fiber, muscle itself, and other deformed soft tissues surrounding the tube. Previously we have studied the distribution of elastic fibers in the rat eustachian tube and ascertained enormous elastin in the cartilage of the eustachian tube. The maintenance of elasticity in the tubal cartilage, related to closing of the eustachian tube, has been suspected as one of important factors in the pathogenesis of otitis media. Rich13) previously described that IGF-I acts as a modulator of the elastogenesis, essential for stretch and recoil actions. However, the examination of the presence of IGF-I in the eustachian tube, especially cartilage may very important as one of factors for well functioning of the eustachian tube. This immunohistochemical study, the tubal cartilage has a considerable content of IGF-I in the capsule around the chondrocytes. The submucosal connective tissue layer of the eustachian tube contained some immunostained cells, considered to be fibroblasts. These findings suggest that IGF-I may be important for normal chondrocyte growth of rat eustachian tube.

Primary Cholesteatoma Originating in the Posterior Fossa / 대한이비인후과학회지

Primary cholesteatomas(epidermoids) originating in the posterior fossa are rare lesions that grow to a large size through slow accumulation of desquamated epithelium. These lesions grow between and ultimately displace cranial nerves, vascular structures, and the brainstem, causing a long course of progressive neurological deficits. Primary cholesteatomas are diagnosed with computed tomography and magnetic resonance imaging. The treatment of choice is surgical excision but portions of the capsule adherent to vital structures should be left undisturbed. Several approaches or combinations of approaches have been utilized to reach the lesions of the ventral brainstem. Among these, the petrosal approach has many advantages. We have experienced a huge primary cholesteatoma of the posterior fossa, so we report with review of literatures.