Successful treatment of progressive Henoch-Schönlein purpura nephritis with tonsillectomy and steroid pulse therapy.

Henoch-Schönlein purpura (HSP) is a systemic disorder characterized by a leukocytoclastic vasculitis involving small vessels with the deposition of IgA immune complexes. The renal involvement is the major cause of morbidity and mortality in patients with HSP. We report here an adult patient with HSP nephritis (HSPN) accompanied by persistent proteinuria and progressive renal dysfunction despite conventional therapy. The patient was successfully treated with tonsillectomy followed by intravenous pulse methylprednisolone and oral prednisone. The combination therapy resulted in a significant decrease in proteinuria, improvement of renal function and the disappearance of microhematuria. The patient finally reached a stage of clinical remission.

[Double anterior (anterolateral and anteromedial) thigh flaps for reconstruction of head and neck defects].

Although the anterolateral and anteromedial thigh flaps have such disadvantages as anatomical variations in the lateral circumflex femoral system and its cutaneous perforators, they have a sufficient number of cutaneous perforators on the anterior aspect of the thigh in many cases, meaning double anterior thigh flaps can be elevated from the ipsilateral thigh. We report 8 cases in which single-pedicle double anterior thigh flaps were transferred for reconstruction of head and neck defects following resection of head and neck tumors from January 1995 to March 2001 at Okayama Saiseikai General Hospital. Eight double anterior thigh flaps were classified into the following 3 types by perforator derivation: Type I flaps consisting of double anterolateral thigh flaps with a single vascular source were elevated in 4 cases. Type II flaps consisting of anterolateral thigh flap and anteromedial thigh flap supplied by separate branches from a single vascular source were elevated in 2 cases. Type III flaps, in which two anterior thigh flaps were harvested separately and constructed into a single flap with microvascular anastomosis, were elevated in 2 cases. Double anterior thigh flaps were combined with vascularized bone, and 2 flaps supplied by independent long vascular pedicles from a single vascular source could be 3-dimensionally arranged. All flaps completely survived in 7 cases and functionally and aesthetically acceptable results were obtained except in 1 case whose flap was lost to major necrosis after infection. We concluded that the single-pedicle double-flap technique using anterior thigh flaps is useful in 3-dimensional reconstruction of massive complex head and neck defects since sufficient tissue implant with preserved blood flow and free flap arrangement is made available.

A novel laser-assisted stapedotomy technique for congenital stapes fixation.

OBJECTIVE: To investigate whether a novel laser-assisted stapedotomy technique is effective in treating congenital stapes fixation. METHODS: With this surgical method, the suprastructure of the stapes is vaporized continuously from the superior half of the anterior crus to the inferior part of the posterior crus using a potassium-titanyl-phosphate (KTP) laser. The midmost point of the vaporization is the head of the stapes. This method was used to treat three patients with congenital stapes fixation (total of four ears). RESULTS: The average hearing gain using this method was 32.2 dB, which lasted for at least 1 year. No complications were observed. CONCLUSIONS: This novel laser-assisted stapedotomy technique is an excellent method for the treatment of congenital stapes fixation.

The potential of a plastination specimen for temporal bone surgery.

OBJECTIVE: The benefits of plastination specimens in temporal bone surgery (TBS) were evaluated. METHODS: A formalin-preserved human temporal bone was drilled and dissected with the middle cranial fossa approach or the translabyrinthine (or transcochlear) approach. The specimen was thereafter subjected to silicon impregnation. RESULTS: The flexibility of the dura mater after plastination was maintained, and not only bony structures such as the auditory ossicles and semicircular canals but also soft tissues such as the facial nerve, internal carotid artery and the sinus attached to the dura mater were easily discriminated. CONCLUSION: The technique furnishes a persistently dry, odorless and durable specimen that allows handling and may serve as the most ideal specimen for anatomical learning of various approaches of TBS.

Surgical intervention in middle-ear cholesterol granuloma.

Eleven patients who had been surgically treated from 1988 to 1999 were retrospectively reviewed in order to evaluate the efficacy of ventilation tube insertion and mastoidectomy with, or without, mastoid obliteration for intractable middle-ear cholesterol granuloma. The mean age registered was 17.2 years at the time of surgical treatment. All cases were unilaterally affected. Five ears were treated with simple mastoidectomy coupled with the insertion of a ventilation tube, while six others had additional mastoid obliteration. The hearing prognosis was excellent with an improved post-operative hearing level of 16.5 dB (cf. pre-operative 37.7 dB). However, morphological prognosis revealed two ears had a residual perforated tympanic membrane without otorrhoea after displacement of the ventilation tube. Of the remaining nine ears with intact placement of the ventilation tube, five had dry ears while four had occasional otorrhoea. Although the morphological prognosis was incomplete, treatments involving at least an insertion of a ventilation tube with thorough mastoidectomy were thought to be necessary.

Protective effect of brain-derived neurotrophic factor against the ototoxicity of Pseudomonas aeruginosa exotoxin A.

OBJECTIVE: The protective effect of brain-derived neurotrophic factor (BDNF) against the ototoxicity resulting from exposure of Pseudomonas aeruginosa exotoxin A (PaExoA) to the middle ear was analyzed. The combined effect of BDNF and N(G)-nitro-L-arginine methyl ester (L-NAME) was also investigated. MATERIAL AND METHODS: Six groups of albino rats were instilled through the tympanic membrane into the round window niche with the following solutions: saline; PaExoA; BDNF; L-NAME; PaExoA + BDNF; and PaExoA + BDNF + L-NAME. Frequency-specific (2-31.5 kHz) auditory brainstem responses were used to obtain the hearing thresholds before and 2, 5 and 15 days after instillation. RESULTS: PaExoA penetrated from the middle ear into the cochlea, causing initially mixed hearing loss, followed by persistent sensorineural hearing loss. This impairment was blocked by BDNF at 6, 8 and 10 kHz on Day 2 and at 8 kHz on Day 5. L-NAME given in combination with BDNF did not show any additional protective effect. There were no significant differences in the thickness of the round window membrane between control ears and those in each instillation group. CONCLUSION: Our results suggest that BDNF may protect against cochlear damage caused by PaExoA in the middle turns of the ear.

Mastoid obliteration by BMP-2/collagen composites: an experimental study using tissue engineering.

PURPOSE: Several materials have been used in the application of mastoid cavity obliteration during surgery for cholesteatoma; however, nothing has won universal acceptance. Through the advancement of tissue engineering, bone morphogenetic protein-2 (BMP-2)/collagen composites have been elucidated as inducers of heterogenic bone formation. This study was performed to investigate whether these composites are potentially obliteration materials for use in the mastoid cavity by using an animal experimental study. MATERIALS AND METHODS: The composites were implanted in the rat mastoid to investigate whether new bone would be tissue engineered in the mastoid and, if so, whether the newly formed bone was stable. The composites were examined histologically over a 24-week period. RESULTS: The composites implanted in the rat mastoid were able to tissue engineer new bone, and the newly formed bone was stable as assessed histologically, with almost normal bone structure, that was not resorbed during the 24-week period. Adverse immunological reactions were not found during our observation. CONCLUSIONS: Bone that was tissue engineered by the BMP-2/collagen composites was stable as assessed by histological examination and persisted in the rat mastoid. The present study shows that the composites have the potential to become real materials for use in mastoid obliteration.

Protective Efect of Brain-derived Neurotrophic Factor Against the Ototoxicity of Pseudomonas aeruginosa Exotoxin A.

Objective--The protective effect of brain-derived neurotrophic factor (BDNF) against the ototoxicity resulting from exposure of Pseudomonas aeruginosa exotoxin A (PaExoA) to the middle ear was analyzed. The combined effect of BDNF and NG-nitro-L-arginine methyl ester (L-NAME) was also investigated. Material and methods--Six groups of albino rats were instilled through the tympanic membrane into the round window niche with the following solutions: saline; PaExoA; BDNF; L-NAME; PaExoA + BDNF; and PaExoA + BDNF + L-NAME. Frequency-specific (2-31.5 kHz) auditory brainstem responses were used to obtain the hearing thresholds before and 2, 5 and 15 days after instillation. Results--PaExoA penetrated from the middle ear into the cochlea, causing initially mixed hearing loss, followed by persistent sensorineural hearing loss. This impairment was blocked by BDNF at 6, 8 and 10 kHz on Day 2 and at 8 kHz on Day 5. L-NAME given in combination with BDNF did not show any additional protective effect. There were no significant differences in the thickness of the round window membrane between control ears and those in each instillation group. Conclusion--Our results suggest that BDNF may protect against cochlear damage caused by PaExoA in the middle turns of the ear.