伊藤 真人

Auditory Neuropathy(AN)は感音難聴を呈するにもかかわらず,耳音響放射(OAE)などで測定する外有毛細胞の機能は正常で,聴性脳幹反応(ABR)では無反応となり,聴力に比して不良な語音明瞭度が特徴とされる疾患概念で,1996年に加我らが"auditory nerve disease"として,Starrらが"Auditory Neuropathy"として最初に報告した.それ以降,類似した臨床所見が集積し研究がすすむ中で,疾患の特徴や病態が報告されている.本稿ではAuditory Neuropathyまたはauditory neuropathy spectrum disorderの背景を述べつつ,海外におけるガイドラインと現況について解説を行った.Auditory Neuropathyは発症時期によって(1)小児や若年期と(2)成人期以降に発症するものに分けられ,それぞれ病態や臨床経過が異なり,それぞれの特徴を理解することで,臨床で出会った際にも,鑑別として挙げることができる.さらに,臨床上見逃さないためのポイントとして,問診,生理検査や画像検査,遺伝子検査について解説した.(著者抄録)

9割以上の医師が漢方薬の処方経験を有するに至っている今日である。一方で「証」を中心とした診断概念は、耳鼻咽喉科ならびに各種診療科においても浸透しているとはいいがたい。本総説では、最初に嗅覚障害に対する漢方医療として当帰芍薬散を紹介する。つづいて口内炎と舌痛症に対する漢方薬治療について半夏瀉心湯と滋陰至宝湯の有効な症例を解説する。その次に、漢方薬のずぶの素人らしく「証」は全く無視して、十全大補湯の有する成分と効能に基づいて当教室が厚労省班研究として施行した頭頸部癌と小児反復性中耳炎に対する多施設共同研究試験の結果について概説する。特に後者の方の臨床試験の結果は「小児急性中耳炎ガイドライン2013」に反映されることとなった。(著者抄録)

  真珠腫性中耳炎に病変の進展範囲に応じて外耳道を拡げるように乳突削開した後（Retrograde mastoidectomy on demand），側頭筋膜片を用いた軟組織にて鼓膜・外耳道を再建する術式を当科では用いている。削開範囲は外耳道を拡大し鼓室の開放にとどまるものから外耳道後壁骨を削除するものまで真珠腫の進展範囲に応じ決定される。長期経過後の術後聴力，真珠腫再発率，最終的な外耳道形態，聴力改善不良例について検討をおこなった。過去の報告と比較し，本術式では聴力経過は全体に良好であり，真珠腫再発率は外耳道を保存する場合より低く，外耳道を削除した場合と同程度であった。外耳道鼓膜の形態は様々であり，個々の中耳換気能により最終的な形態に落ち着くものと考える。また，聴力改善不良例は乳突部と耳管鼓室口への進展を多くみとめ，耳管機能不全が疑われた。聴力改善には中耳換気能が重要であると考える。

We report herein on a rare case of schwannoma of the chorda tympani with facial palsy. A 34-year-old woman was referred to our hospital because of right facial palsy which was resistant to steroid intervention and anti-viral drugs. In the physical examination, a white mass was observed in the posterior superior quadrant of the tympanic membrane and the facial palsy score was 0/40. Computed tomography revealed a tumor in the right chorda tympani, extending from the branch of facial nerve to the malleus. Based on the physical, physiological and imaging tests, the patient was diagnosed as having a tumor of the right chorda tympani with facial palsy. For the purpose of resection and definitive diagnosis of the tumor, a surgical intervention was performed. Histologically the tumor was diagnosed as a schwannoma, and immunohistochemically the tumor cells were positive for S-100. After surgery, the patient's facial palsy completely resolved in six weeks. There has been no finding of recurrence two years after surgery.

We retrospectively examined the bacterial isolates, tolerance to antibiotics, and clinical course in 88 patients with peritonsillar abscess who were treated at the Matto Ishikawa Public Central Hospital between October 2007 and December 2012. Peritonsillar pus was collected by needle aspiration in 57 cases, and 90 strains of bacteria were detected and tested for drug sensitivity. In 16 cases (32%), only anaerobes were cultured. In 18 cases (35%), only aerobes were cultured. And in 16 cases (28%), both anaerobes and aerobes were cultured. In 3 cases (5%), neither anaerobes nor aerobes were detected. Overall, 6 of the 41 anaerobic strains (14. 6%) and 8 of the 35 aerobic strains (22. 9%) were resistant to clindamycin(CLDM). None of the 25 anaerobes were resistant to ampicillin/sulbactam (ABPC/SBT). The rate of resistance to ABPC/SBT among the aerobes was less than or equal to the rate of the resistance of aerobes to ABPC (9. 8%). Against carbapenem (CBP), all 42 anaerobic strains did not have any tolerance, and only 2 of the 42 aerobes were resistant (4. 8%). Judging from the above, ABPC/SBT might be suitable as a first-line antibiotic for the treatment of peritonsillar abscess, rather than CLDM, because of the low rate of drug resistance and the narrow spectrum. CBP should be regarded as a second-line treatment, since CBP abuse can induce tolerance.

Clinical usefulness of olopatadine hydrochloride was studied in 97 patients with cedar pollinosis in 2005. The subjects were divided into 2 groups based on the time of starting treatment before or after the onset of pollen season. Subjective symptoms, objective findings of nose and quality of life scores using Japanese Rhino-conjunctivitis Quality of Life Questionnaire (JRQLQ No 1) were compared between the two groups. Both the clinical scores and QOL scores remained normal even at the peak of pollen scattering in patients who started medication before pollen season, and showed significant differences in each index compared with those in the patient group starting treatment after the onset of pollen season. The patients who started medication after pollen dispersal were not relieved of their symptoms at the peak of pollen scattering, but they had lower scores at both the beginning and end of pollen season. There were strong correlations between the clinical symptom scores and QOL scores in both groups. In conclusion, olopatadine hydrochloride appeared to be sufficiently effective for cedar pollinosis during the season of peak pollen of scattering by starting medication before the onset of pollen season.

Objective: A rapid increase of penicillin resistance in Streptococcus pneumoniae has recently been reported in most areas of the world. Penicillin-resistant S. pneumoniae and other resistant bacteria are the principal causes of recurrent acute otitis media (AOM). Penicillin-resistant S. pneumoniae was examined so that we could investigate the bacteriologic and clinical interpretations of nasopharyngeal flora from healthy children. Methods: We obtained nasopharyngeal swab specimens from healthy children attending a day care center and from children attending a public health examination in Kanazawa, Japan. We also obtained clinical specimens from children with AOM who visited the Kanazawa University Hospital and 4 other hospitals in Ishikawa Prefecture in Japan. Results: The chief bacteria from the children were S. pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Penicillin-resistant S. pneumoniae was identified in 75% of children attending a day care center. On the other hand, S. pneumoniae was identified in 37% of children who were not attending day care. Of the children with AOM, penicillin-resistant S. pneumoniae was identified in 77%. Conclusion: Our results suggest that there is a strong relationship between day care attendance and nasopharyngeal carriage of S. pneumoniae. The carriage rate of penicillin-resistant S. pneumoniae in healthy children in day care centers was very high and similar to the carriage rate of young patients with AOM in Japan.

The projections to physiologically defined tonotopic regions of the central nucleus of the inferior colliculus (ICC) from the adult rat's superior olivary complex (SOC) and lateral lemniscus were investigated using retrograde tract tracing methods. Iontophoretic injections of the retrograde tracers; Fluoro-Gold (FG) or-horseradish peroxidase (HRP), were made into the ICC through a glass micropipette, which also served as a recording electrode to determine the frequency response at the injection site. Injections were made into frequency-specific regions based on the best responses of neurons to contralaterally presented tones between 2-25 kHz. In the dorsal nucleus of the lateral lemniscus (DNLL) neurons were labeled both ipsilaterally and contralaterally to the injection site with a larger proportion pi-ejecting to the contralateral side. Th-distribution of labeled cells was concentric, with high frequencies represented along the outer margin and low frequencies represented centrally within DNLL. The lateral superior olive (LSO) was labeled bilaterally, with high frequencies represented medially and low frequencies laterally along the nuclear axis. The projection from the medial superior olive (MSG) was ipsilateral, with high frequencies represented ventrally and low frequencies dorsally. The projection from the superior paraolivary nucleus (SPN) was also largely ipsilateral, with high frequencies represented medially and low frequencies laterally. The intermediate and ventral nuclei of the lateral lemniscus (INLL and VNLL) were also labeled ipsilaterally and exhibited a distribution of tracer that depended on the frequency of the injection site: the low frequency projection was banded but the high frequency projection was more evenly distributed. (C) 1998 Elsevier Science B.V.

Ectasia of the jugular system is unusual in children. We present here a pediatric case with internal jugular vein phlebectasia, and an adult case with a venous aneurysm. These two ectasias were observed as nonpulsatile, elongated or round neck masses that enlarges with the Valsalva maneuver or speaking. Computed tomography (CT), magnetic resonance imaging (MRI), ultrasound and angiography have all been used in the diagnosis of ectasia. However, CT with a contrast agent make it possible to obtain a clear diagnosis, and allows the detection of thrombus formation.<br>In our adult case, a thrombus in the aneurysm was suggested. After CT with a contrast agent, angiography was useful to detect the thrombosis and its connection with the internal jugular vein. Surgical resection of the jugular aneurysm was undertaken to avoid the risk of embolization in this case. In our pediatric case, the phlebectasia has been examined regularly because the lesion was stable in size, and there was no thrombus formation. We recommend surgical resection only if the lesion forms a thrombus, increases in size, or causes cosmetic deformity.