金澤 丈治

成人の弛緩部型真珠腫の臨床像に年齢による違いがみられるか検討をおこなった。対象は当院で鼓室形成術をおこなった弛緩部型真珠腫新鮮例99耳とし、20歳代および30歳代を若年群（41耳）、50歳代および60歳代を高齢群（42耳）とし以下の3項目、1）術前の側頭骨CTをもとに計測した乳突蜂巣断面積、2）術後中耳腔含気化の程度、3）日本耳科学会2000年度案に基づいた術後聴力成績、に関して比較検討をおこなった。結果、以下のごとく統計学的に有意差を認めた。1）若年群は有意に乳突蜂巣断面積が大きい（P＜0.001、t検定）。2）若年群は術後乳突蜂巣の含気化が有意に良好（P<0.001、χ<SUP>2</SUP>検定）。3）若年群は術後聴力成績が有意に良好（P<0.001、χ<SUP>2</SUP>検定）。年齢により成人の弛緩部型真珠腫の臨床像に大きな違いがみられた。この２群間において真珠腫の成因が異なっている可能性があると推察された。

症例は51歳男性。他院にて左弛緩部型真珠腫に対し外耳道再建型鼓室形成術を受けた。術後しばらくしてから朝方に強い難聴を自覚するようになり、聴力は変動した。耳管機能不全として加療するも改善せず当科紹介となった。耳鏡所見で左外耳道後壁の膨隆を認めた。側頭骨CTにて外耳道後壁に骨欠損部位があり、空気による外耳道膨隆であった。よって骨欠損部の硬性再建および換気経路の再確保のため左鼓室形成術をおこなった。術中鼓室峡部にウェブの形成があり、これを開放し骨欠損部を軟骨、皮質骨を用いて再建した。術後聴力は著明に改善し、現在のところ経過良好である。本症例は、正常な乳突腔粘膜のガス拡散能を証明する一例と考えられた。

We report two cases of otitis media positive for antimyeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) associated with facial palsy. Case 1: A 73-year-old man treated for 3 months for bilateral otitis media with effusion had left facial nerve palsy and deteriorated bone conduction hearing in both ears. Blood analysis showed elevated MPO-ANCA to 134 EU. Case 2: A 66-year-old woman treated for about one year for bilateral otitis media with effusion and fluctuating mixed hearing loss had bilateral facial nerve palsy and a blood test positive for MPO-ANCA at 67 EU. Both were diagnosed with otitis media caused by ANCA-related vasculitis. After prednisolone and cyclophosphamide administration for half a year, blood test results were negative for MPO-ANCA. Both recovered almost completely from facial nerve palsy and bone conductive hearing loss partially improved except in one hearing-impaired ear. ANCA-related vasculitis of the temporal bone should thus be considered in those with intractable otitis media and deteriorated bone conduction hearing before the occurrence of facial palsy.

Wegener's granulomatosis (WG) is characterized by granulomatous inflammation involving the upper and lower respiratory tracts and necrotizing vasculitis affecting small to medium-sized vessels. Here, we report the cases of three patients presenting with intractable otitis media with progressive hearing loss as an initial sign. In two patients, a definite diagnosis of WG was made serologically and histopathologically. Although one patient was negative for any test for WG, he was administered predonisolone and cyclophosphamide as a diagnositic medication. All other patients were treated with satisfactory outcomes including hearing improve-ment. In patients with a limited form of WG in the ear and nose who had been previously reported, it iwas difficult to obtain a definite diagnosis by serological or histlogical tests, and a positeve C (PR-3)-ANCA seemed to be a risk facter of poor hearing recovery. However, the hearing could be improved even in patients with a positive C (PR-3)-ANCA if the immunosuppressive medication is administered as quickly as possible. Therefore, precise diagnosis including the diagnositic medication for WG and quick therapeutic intervention are required to interrupt the spread of necrotizing vasculitis to other organs and to improve hearing

Group A streptococci may cause a variety of infections, some of which are severe and may be lifethreatening. Patients affected by severe invasive group A streptococcal infection may develop a syndrome characterized by circulatory insufficiency with multiple organ failure, namely, streptococcal toxic shock-like syndrome (TSLS). Here, we report a case of streptococcal TSLS originating from the left neck. A 70-year-old man was referred to our hospital with a diagnosis of deep neck and mediastinal infection. Debridement of his left neck and drainage of anterior and posterior parts of the mediastinum were immediately performed. As Group A streptococci were detected from the effusion and blood, he was diagnosed as having streptococcal TSLS. Intensive systemic care involving long-term administration of penicillin G in addition to drainage of the infection helped him recover from TSLS. He underwent further debridement twice to control local infection. Early diagnosis of and surgical intervention for TSLS are mandatory. Subsequently, appropriate supportive treatment of vital organ dysfunction and administration of penicillin as the antibiotic of choice represent the cornerstones of the management of this syndrome.

耳下腺腫瘍は, 日常臨床において比較的よく遭遇する疾患である. 耳下腺腫瘍に対する治療は手術が基本であり, 確定診断のためにも手術が行われる. このため耳下腺腫瘍手術の習得は, 耳鼻咽喉科専門医研修のなかでも重要な到達目標のひとつと考える. 今回, 平成12年1月より平成19年4月までに自治医科大学附属さいたま医療センター耳鼻咽喉科を受診した86例の耳下腺腫瘍患者のうち多形腺腫43例, ワルチン腫瘍28例の計71例に関して, 手術時間とそれに関連する因子 (年齢, 性別, 手術側, 合併症の有無, BMI, 出血量, 腫瘍径, 発生部位, 露出した顔面神経, 術者の経験) について多変量解析をおこなった. この結果, 年齢, 性別, 手術側, 合併症の有無, BMI, 露出した顔面神経については手術時間との関連は認めなかったものの, 出血量, 腫瘍径, 発生部位, 術者の経験については有意な相関を示した. また, 20-39例経験した術者の平均手術時間と40例以上経験した術者の平均手術時間は概ね同等であったことから手術時間が安定するまでには30-40例の経験が必要と思われた. この結果, 手術時間を短縮するためには経験の少ない術者は腫瘍径が小さく下極に存在する腫瘍から研鑽をはじめ経験が増すにつれて大きくて浅葉や深葉に存在する症例を経験していくことが望ましいと思われた. また, 手術時間が安定する30-40例までは熟練した指導医の補佐が必要な時期と考えた.

The application of adeno-associated virus (AAV) vectors to cancers is limited by their low transduction efficiency. Previously, we reported that gamma-ray enhanced the second-strand synthesis, leading to the improvement of the transgene expression, and cytocidal effect of the herpes simplex virus type-1 thymidine kinase (HSVtk) and ganciclovir (GCV) system. In this study, we extended this in vitro findings to in vivo. First, the laryngeal cancer cell line (HEp-2) and HeLa were treated with AAVtk/GCV, the number of surviving cells was reduced as the concentration of GCV increased. Furthermore, the 4 Gy irradiation enhanced the killing effects of AAVtk/GCV by four-fold on HeLa cells and 15-fold on HEp-2 cells. Following the in vitro experiments, we evaluated the transgene expression and the antitumor activity of the AA V vectors in combination with gamma-ray in nude mice inoculated with HEp-2 subcutaneously. The LacZ expression was observed in the xenografted tumors and significantly increased by gamma-ray. The AAVtk/GCV system suppressed the tumors growth, and gamma-ray augmented the antitumor activity by five-fold. These findings suggest that the combination of AAVtk/GCV system with radiotherapy is significantly effective in the treatment of cancers and may lead to reduction of the potential toxicity of both AAVtk/GCV and gamma-ray.

Only nine cases of primary verrucous carcinoma of the temporal bone have been reported in the English literature. We describe histopathologic findings in a 78-year-old man dying of intracranial complications of primary verrucous carcinoma of the external auditory canal. Following autopsy the temporal bone was prepared for light microscopic examination. The temporal bone was serially sectioned horizontally after fixation, decalcification, and embedding, and each 10th section was stained with hematoxylin and eosin and examined by light microscopy. The carcinoma originated from the external auditory canal, infiltrating the mastoid cavity, the middle ear, tissue adjacent to the internal carotid artery, and the posterior cranial fossa, where it invaded the right cerebellum and produced an abscess. The labyrinth and internal auditory canal were not infiltrated. Metastasis to lymph nodes or distant sites was not identified. In the present case, the verrucous carcinoma originating from the external auditory canal extended into the posterior cranial fossa, while it did not invade the membranous labyrinth. (C) 2000 Elsevier Science Ireland Ltd.

The efficacy of chemotherapy for unresectable recurrent or metastatic squamous cell carcinomas of the head and neck can not be proved by survival periods. However, the efficacy of chemotherapy has been observed in some select patients. We investigated the effect of chemotherapy for unresectable recurrent squamous cell carcinomas of the head and neck. Four patients with a good performance status (PS) were treated with high-doses of leucovorin (LV), cisplatin (CDDP), and 5-fluorouracil (5-FU). The regimen consisted of 25mg/m2 of CDDP on days 1-5; 600mg/m2 of 5-FU of days 2-6; and 200mg/m2 of LV on days 1-6. Patients received 3 cycles of this regimen at 28-day intervals.Ten patients with a poor PS were treated with low-doses of CDDP and tegafur•uracil upon admission. The regimen of seven poor PS patients consisted of 8mg/m2 of CDDP on days 1-5 and 8-12, and 400mg/body of tegafur•uracil administered orally on days 1-14. The other three patients received chemotherapy on an outpatient basis for ten weeks. The weekly regimen consisted of 7.5mg/m2 of CDDP on days 3 and 6 and 400mg/body of tegafur•uracil administered orally on days 1-7. With respect to the LV+CDDP and 5-FU treatment, complete remission was obtained in one patient. Two patients showed no change (NC), while one patient developed a progressive disease (PD). This regimen is highly toxic, has severe side effects including myelosuppression, oral mucositis, and diarrhea, and has a survival period of between 16 and 32 weeks. The low-dose CDDP+tegafur•uracil treatment produced a partial response in three patients, NC in three patlents, and four patients developed a PD. This regimen doses not have any severe side effects and has a survival period of between 4 and 67 weeks.

Thirty-two patients with inoperable head and neck cancer seen at Jichi Medical School Hospital during the period 1978 to 1995 were analyzed. Distribution of the affected site was as follows: 15 cases of oropharynx, 12 of hypopharynx, and 3 of larynx. In order to study a better performance status, prognosis and side effects were compared between radiotherapy alone (17 patients) and combined radiochemotherapy (15 patients). Patients who received the combined therapy survived longer than those patients who received radiotherapy alone. Moreover, high QOL was obtained longer in the combined therapy.<BR>Therefore, we conclude that radiotherapy should be combined with chemotherapy for cases with inoperable head and neck cancer.

A 64-year-old man with well-differentiated squamous cell carcinoma of the maxilla who presented with high levels of granulocyte-colony stimulating factor (G-CSF) is described. The extent of the tumor was staged as T4N1M0. Regional chemotherapy, radiotherapy and resection of the tumor were performed. The patient died of local recurrence and lung metastasis about four months after admission. During his clinical course, a peripheral blood analysis demonstrated marked granulocytosis and high G-CSF activity. G-CSF producing cancer cells were immunohistologically observed in the primary lesion and metastatic lymph nodes. Therefore, he was diagnosed with G-CSF producing maxillary cancer. The cancer tissue from this patient was transplanted into nude mice, and one of these mice demonstrated distant metastasis to the lung.

This report presents two elderly patients with a rhabdomyosarcoma of the paranasal sinus.Case 1 was a 79 year-old woman CT and MRI findings revealed a massive tumor extending from the right ethmoid sinus to the anterior skull base. Apathological study of the biopsied specimen based on immunochemical histology and electronmic roscopic examination indicated rhabdomyosarcoma. Irradiation and local chemotherapy followed by en-bloc resection of the tumor was performed. She died from unrelated disease.Case 2 was a 73 year-old man with a massive tumor was located in the right maxillary sinus. The pathological diagnosis was rhabdomyosarcoma. Partial maxillectomy and irradiation was performed. He has remained free from disease eleven months after admission.Rhabdomyosarcoma in the aged is very rare and the standard treatment is such cases has not been established. The present study suggested that surgery and irradiation might be effective in the treatment of elderly patients with rhabdomyosarcoma of the paranasal sinus.

The outcome of radiation therapy or surgery was studied retrospectively in 30 previously untreated patients with squamous cell carcinoma (SCC) of the lateral wall of the oropharynx. Twenty-two patients with tonsillar SCC and 8 patients with tonsillar pillar SCC were treated between 1978 and 1997 at the Jichi Medical School Hospital. The group consisted of 25 men and 5 women, aged 34 to 82 years (average, 63 years). In the tonsillar SCC group, lesions were T1 in 2 cases, T2 in 2, T3 in 13, and T4 in 5; 5, 3, 12 and 2 patients had NO, N1, N2, and N3 disease, respectively. In the tonsillar pillar SCC group, lesions were T2 in 5 cases, T3 in 2, and T4 in 1; 6 patients had NO, 1 had N1, and 1 had N2 disease. Fourteen patients were treated with radiation and 16 were treated with surgery, 14 of whom also received preoperative irradiation. Eleven patients in the surgery group underwent resection by a transoral approach and 5 underwent extended surgery with reconstruction. Disease-free survival rate at 3 years by the Kaplan-Meier method was 64% in the radiation group and 78% in the surgery group (not significantly different) in those with tonsillar SCC, and 67% and 82%, respectively, (not significantly different) in those with tonsillar pillar SCC. The surgical approach was transoral in patients with noninvasive T2 or T3 primary lesions. No local recurrence was observed. Transoral resection appears to be useful for treating noninvasive lateral wall SCC of the oropharynx.