Decision making for position-dependent obstructive sleep apnea syndrome on the basis of patient information and physical examinations of the upper airway, acquired on an outpatient basis.

CONCLUSIONS: Patients with body mass index (BMI) < 25 kg/m2 and obstructive sleep apnea syndrome (OSAS) are highly suspicious for position-dependent OSAS. Diagnosis of position-dependent/position-independent OSAS can be difficult in patients satisfying both 'BMI >25 kg/m2' and 'any of tongue enlargement (TE), palatine tonsil hypertrophy (PTH) and obstruction by Muller's maneuver (OMM)'. Polysomnography is warranted in such patients. OBJECTIVES: The objective was to retrospectively elucidate criteria for differentiating position-dependent OSAS on the basis of patient information and physical examinations of the upper airway obtainable in clinics. METHODS: The 643 patients were categorized as positional patients (PPs) or non-positional patients (NPPs). The patient background factors examined were sex, age, BMI, and hypertension. TE, PTH, pharyngeal tonsil hypertrophy, and OMM were evaluated. Cross-validation was performed using even-numbered registrations as the training set group (Group A) and odd-numbered registrations as the test case group (Group B). RESULTS: In Group A, patients with BMI <25 kg/m2 were clearly more frequent among PP than among NPP. In Group A with BMI ≥25 kg/m2, significant differences were found for TE, PTH and OMM. Significant differences were found between 0 and 1/2/3 for number of factors. Results generated from Group A were validated in Group B.

Deep neck cellulitis: limitations of conservative treatment with antibiotics.

CONCLUSION: When the parapharyngeal space is infected, concurrent involvement of other spaces is likely, and involvement of multiple deep neck spaces is a key risk factor for abscess formation. OBJECTIVES: Deep neck infection is treated with antibiotics when abscesses have not yet been formed. However, in some cases, abscesses will form later and surgical drainage is warranted. This study retrospectively examined which cases were less likely to achieve cure, to clarify the limitations of conservative treatment for deep neck cellulitis. PATIENTS AND METHODS: Subjects comprised 19 patients with deep neck cellulitis who initially underwent conservative treatment with antibiotics. Patients were divided into two groups: Group A (n = 7), patients who recovered by conservative treatment; and Group B (n = 12), patients who did not recover and underwent surgical drainage. Age, state of DM control, etiology, treatment, spaces infected, and duration of hospitalization were investigated. RESULTS: The number of infected spaces was one in all Group A patients, whereas Group B showed multiple infected spaces in all except two cases. In particular, among the 10 cases with parapharyngeal space infection, eight (80%) showed multiple lesions.

Prospective Randomized Trial on Postoperative Administration of Diet Containing Eicosapentaenoic Acid, Docosahexaenoic Acid, Gamma-linolenic Acid, and Antioxidants in Head and Neck Cancer Surgery Patients with Free-flap Reconstruction.

OBJECTIVES: The purpose of this prospective, randomized study was to evaluate the effects of a diet containing eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), gamma-linolenic acid (GLA), and antioxidants in head and neck cancer surgery patients with free-flap reconstruction. METHODS: In this randomized, prospective study, 62 patients with head and neck cancers were assigned to receive a general control diet (Ensure(®) H; Abbott Japan, Tokyo, Japan) or the study diet (Oxepa(®); Abbott Japan) containing EPA, DHA, GLA, and antioxidants (eg vitamins A, E, and C). The primary assessment item was the degree of postoperative inflammation, as assessed by measuring maximum body temperature and levels of C-reactive protein (CRP) and procalcitonin from the day of surgery to postoperative day 8. Secondary assessment items were lengths of stays in the intensive care unit (ICU) and hospital. RESULTS: The control diet group (n = 32) and study diet group (n = 30) showed no significant difference in energy administered through diet. No significant differences in the parameters of the primary assessment item were noted. Length of stay in the ICU was significantly shorter for the control diet group than for the study diet group (P = 0.011). No significant difference in duration of hospitalization was seen between groups. CONCLUSION: No usefulness of a diet containing EPA, DHA, GLA, and antioxidants was demonstrated.

Antiemetic therapy of fosaprepitant, palonosetron, and dexamethasone combined with cisplatin-based chemotherapy for head and neck carcinomas.

CONCLUSION: Concomitant antiemetic therapy comprising fosaprepitant, palonosetron, and dexamethasone is effective for head and neck carcinoma. OBJECTIVE: A patient diary was constructed to determine the effectiveness of concomitant antiemetic therapy with a neurokinin-1 receptor antagonist (fosaprepitant), 5-hydroxytryptamine receptor antagonist (palonosetron), and dexamethasone in accordance with guidelines. METHODS: Subjects comprised 41 patients who received 71 courses of chemotherapy, along with fosaprepitant, palonosetron, and dexamethasone. A patient diary was compiled concerning the presence/absence of vomiting, vomiting episodes, presence/absence of rescue therapy, food intake, presence/absence of nausea, and general condition. RESULTS: The frequency of the primary end point of complete response in the overall phase was 69.0%. The proportion of patients with no vomiting in the overall phase was 90.1%. In the acute phase, the proportion of no nausea and slight nausea together was 91.5%, no change in and slightly reduced food intake together was 87.3%, and the proportion of good general condition and relatively good general condition was 85.9%. In the delayed phase, the proportion of no nausea and slight nausea together was 56.3%, no change in and slightly reduced food intake together was 43.7%, and the proportion of good general condition and relatively good general condition together was 53.5%.

Patella dislocation following distal femoral replacement after bone tumour resection.

We report the case of a 16-year-old girl with patella dislocation following distal femur replacement for a malignant tumour. We performed a medial plication and lateral release procedure to treat her persistent patellar dislocation after distal femur replacement following malignant tumour resection. This treatment improved the patient's gait ability dramatically. A distal femur reconstruction with a total knee arthroplasty (TKA) system for tumour resection is a frequently performed procedure. The reported incidence of patella dislocation following distal femur reconstruction with a TKA is 2.3%. However, treatment procedures for patella dislocation following a distal femur replacement after malignant tumour resection have not been studied extensively. To the best of our knowledge, this is the first English case report about patella dislocation following distal femoral replacement focusing on surgical treatment. Our experience suggests that treatment for patella dislocation following distal femur reconstruction with a TKA should be considered positively.

A case of giant osteoma in the middle turbinate of a child.

Only seven cases of osteoma arising in the middle turbinate have been reported to date. We report the eighth case, involving osteoma in the middle turbinate of a child. This young boy was initially examined at the age of nine for the main complaint of nasal obstruction. Although a large osteoma with a maximum diameter of 30 mm was observed on computed tomography (CT), the patient was only observed because of the wishes of the family. At 13 years, he was again examined, as a result of worsening of the nasal obstruction. CT revealed that the osteoma had enlarged to a maximum diameter of 41 mm. Endoscopic surgery was attempted, but because of difficulties, the osteoma instead had to be removed under direct vision via a gingival incision. The final pathological diagnosis was osteoid osteoma. The nasal obstruction disappeared following surgery, with no recurrence after more than 12 months postoperatively.

Joint use of skull base surgery in a case of pediatric parotid gland carcinoma.

Parotid gland carcinoma is extremely rare in children. We report a case of pediatric parotid gland carcinoma with extensive infiltration into surrounding tissues including the skin and temporomandibular joint capsule at initial examination. Total resection of the parotid gland was conducted together with skull base surgery and mandibular dissection. The patient was a 14-year-old girl. In addition to the skin and temporomandibular joint, infiltration into the anterior wall of the external auditory meatus and masseter muscle was also seen, and T4N0M0 stage IV parotid carcinoma was diagnosed. Skin was resected together with the pinna, and temporal craniotomy and skull base surgery were performed to resect the temporomandibular joint capsule and external auditory meatus en bloc, and mandible dissection was conducted. Facial nerves were resected at the same time. Level I to level IV neck dissection was also conducted. A latissimus dorsi myocutaneous flap was used for reconstruction. The postoperative permanent pathology diagnosis was high-grade mucoepidermoid carcinoma with a low-grade component. Postoperatively, radiotherapy at 50 Gy alone has been conducted, with no recurrence or metastasis observed for over 4 years.

Secondary insertion of Provox(®)2 using an endotracheal tube.

CONCLUSION: A procedure with no exploratory puncture using an endotracheal tube, sharp-tipped trocar, flexible fiberscope, and flexible guidewire is useful for inserting the Provox(®)2 prosthesis. OBJECTIVES: The purpose of the present study was to examine the necessity of exploratory puncture in consideration of operating time, complications, and voice rehabilitation. METHODS: Insertion of the Provox(®)2 was conducted using an endotracheal tube, sharp-tipped trocar, flexible fiberscope, and flexible guidewire under general anesthesia. This was performed in conjunction with exploratory puncture in the first 7 patients, and without exploratory puncture in the following 15 patients. RESULTS: Operating time was 10 min in the group with exploratory puncture and 6 min in the group without exploratory puncture. Although a shorter size had to be substituted in one patient without exploratory puncture on the day following the procedure due to difficulty with eating, no complications due to the procedure were observed in any patients. Speech production was possible in all patients on the following day.

A case report of malignant melanoma of the sphenoid sinus.

Malignant melanoma of the sphenoid sinus is a very rare disease, and only 6 cases have previously been reported. The present case involved a 74-year-old woman who was examined for visual disturbance of the left eye. Computed tomography revealed a soft tissue shadow, but only mucosal hypertrophy was found on opening the sphenoid sinus under general anesthesia. One month postoperatively, visual disturbance of the right eye and paresis of cranial nerve III appeared. Malignant melanoma was diagnosed from biopsy. Multiple bone metastases were identified, but the patient declined active treatment. As a result, palliative care was provided and she died 3 months later. When there is no improvement in postoperative visual acuity as in this case, in consideration of the possibility of neoplastic lesions, rigorous followup including monitoring for neurological symptoms is warranted.

[A recalcitrant case of encephalitis with voltage-gated potassium channel antibodies].

We report the case of a 65-year-old man who had encephalitis with a high titer of voltage-gated potassium channel antibodies (VGKC-Abs). His initial symptoms included memory disturbance, confusion, and seizures. Laboratory tests revealed a low plasma sodium concentration and a strong positive result for VGKC-Abs. A diffusion-weighted magnetic resonance imaging (MRI) scan showed a high intensity lesion within the right basal ganglia, which later showed normal intensity. The patient's initial symptoms resolved without any treatment. During the first relapse, the patient experienced consciousness disturbance and an increased number of seizures than that observed initially. A diffusion weighted MRI scan showed a high intensity lesion within the right hippocampus, and a fluid attenuated inversion recovery (FLAIR) weighted MRI scan showed high intensity lesions within the right hippocampus, right thalamus, and pons. The patient's symptoms and the MRI abnormalities resolved with prednisolone therapy. During the second relapse, he again experienced consciousness disturbance and an increased number of seizures than that observed initially. Diffusion-and FLAIR weighted MRI scans showed high intensity lesions within the right thalamus. However, the array of immunosuppressive treatments used during the first relapse was not as effective during the second relapse. The serum VGKC-Ab titers before steroid therapy during the first relapse and after immunosuppressive treatment during the second relapse were 1,252 pmol/L and 22.4 pmol/L, respectively. Brain MRI revealed signal changes in the basal ganglia at the onset of disease, in the limbic area during the first relapse, and in the thalamus during the second relapse. VGKC-Ab-associated encephalopathy is usually considered a benign autoimmune disorder; however, in our case, the encephalitis gradually became intractable to various immunosuppressive treatments, and unique MRI abnormalities were observed.

Alzheimer's disease: report of two autopsy cases with a clinical diagnosis of corticobasal degeneration.

Alzheimer's disease (AD) is the most common cause of dementia in the elderly. Corticobasal degeneration (CBD) is a rare neurodegenerative disease affecting adults, being characterized clinically by a combination of extrapyramidal signs and focal cortical syndromes. In both diseases, tau deposits are a characteristic neuropathological feature. We report two new patients with autopsy-proven AD, in whom clinical diagnoses of CBD were made during life. The ages of the patients at onset were 52 and 67 years, and the disease durations were 9 and 15 years, respectively. At autopsy, both cases exhibited marked cortical atrophy with evident neuronal loss in the convex areas of the frontal and parietal lobes. Immunohistochemically, AT8-positive neurofibrillary tangles (NFTs) and Abeta-positive senile plaques (SPs) were widespread and abundant in the cerebral cortex (Alzheimer pathology stage VI/C of Braak and Braak), leading us to the final pathological diagnosis of AD. No tau lesions suggestive of CBD were observed, and the deep gray matter areas, including the substantia nigra, were unremarkable (exceptionally, only mild neuronal loss was noted in the putamen in case 2). These findings further strengthen the idea that in AD, neurodegeneration with tau and Abeta deposits may begin in the fronto-parietal neocortical areas, which are often preferentially affected in CBD, earlier than, or as early as the medial temporal lobe, and that extrapyramidal signs, such as rigidity and tremor, can occur in the absence of neuronal loss in the basal ganglia and substantia nigra.

Clinical utility of diffusion tensor imaging for evaluating patients with diffuse axonal injury and cognitive disorders in the chronic stage.

Although diffuse axonal injury (DAI) usually ellicits cognitive disorders, abnormal brain findings are generally undetected by conventional imaging techniques. The aim of this study was to evaluate the feasibility of using diffusion tensor imaging (DTI) to detect lesions in DAI patients and to investigate the correlation between DAI lesions and cognitive disorders. We examined 16 healthy controls and 11 patients with DAI. Using voxel-based analysis, we found that there were significantly more brain regions with decreased fractional anisotropy (FA) in the brain but DAI patients compared to healthy controls (p < 0.001), whereas few lesions were detected via conventional magnetic resonance imaging. There was a significant relationship between the results of the Wechsler Adult Intelligence Scale-Revised, Trail Making Test, and some indices of the Wechsler Memory Scale-Revised and the decreased FA observed in various areas of the brain (p < 0.001). The total cognitive scores on the functional independence and functional assessment measures, which represent behavioral problems, were correlated with the cluster (number of DAI lesions, p = 0.007) and voxel numbers (total size of all DAI lesions, p = 0.001). In the fiber tractography-based analysis, DAI patients with memory disorders showed an interruption of fibers within the fornix compared to healthy controls. These results indicate that DTI is a useful technique not only for detecting DAI lesions but also for examining cognitive disorders in DAI patients.

Diffusion tensor imaging fiber tractography for evaluating diffuse axonal injury.

Patients with Diffuse axonal injury (DAI) frequently exhibit cognitive disorders chronically. Radiologic recognition of DAI can help understand the clinical syndrome and to make treatment decisions. However, CT and conventional MRI are often normal or demonstrate lesions that are poorly related to the cognitive disorders. Recently, diffusion tensor imaging (DTI) fiber tractography has been shown to be useful in detecting various types of white matter damage. The aim of this study was to evaluate the feasibility of using DTI fiber tractography to detect lesions in DAI patients, and to correlate the DAI lesions with the cognitive disorders. We investigated two patients with chronic DAI. Both had impaired intelligence, as well as attention and memory disorders that restricted their activities of daily living. In both patients, DTI fiber tractography revealed interruption of the white matter fibers in the corpus collosum and the fornix, while no lesions were found on conventional MRI. The interruption of the fornix which involves the circuit of Papez potentially correlates with the memory disorder. Therefore, DTI fiber tractography may be a useful technique for the evaluation of DAI patients with cognitive disorders.

Loss of aquaporin-4 in active perivascular lesions in neuromyelitis optica: a case report.

Neuromyelitis optica (NMO) is clinically characterized by severe optic neuritis and transverse myelitis. In Japan, NMO has been named optic-spinal multiple sclerosis (OSMS) and it has been thought to be a subtype of multiple sclerosis (MS). However, several clinical and laboratory findings suggest NMO or OSMS is distinct from MS. Recently, the disease-specific antibody (NMO-IgG) was found in the serum from NMO patients, and its target antigen was identified as aquaporin-4 (AQP4) water channel protein which is mainly expressed in astroglial foot processes. However, the pathogenetic role of AQP4 in NMO remains unknown. We herein report a typical case of NMO in which immunohistochemical analysis showed a lack of AQP4 in the spinal cord lesions. The loss of AQP4 was evident in the central gray matter, especially in the perivascular lesions where immunoglobulins and complements were deposited, and glial fibrillary acidic protein (GFAP) staining was weak in those lesions. However, GFAP was strongly stained at the reactive astrogliosis surrounding the lesions. Myelin basic protein (MBP)-stained myelinated fibers were relatively preserved in the lesions where AQP4 was lost. In contrast to these NMO lesions, AQP4 was expressed predominantly in the gray matter in control spinal cords, and AQP4 was preserved in demyelinating MS lesions. Our findings suggest that astrocytic impairment associated with humoral immunity against AQP4 may be primarily involved in the lesion formation of NMO, and that the pathomechanisms of NMO are different from those of MS in which demyelination is the primary pathology.

Sacsin-related autosomal recessive ataxia without prominent retinal myelinated fibers in Japan.

Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) has been described in the Quebec region and in Tunisia. We report on two Japanese siblings with a new homozygous mutation (6543 del A) of the SACS gene. Compared with previously reported ARSACS patients, both of these patients had a unique phenotype characterized by dementia, ophthalmoplegia, and the absence of prominent retinal myelinated fibers.