Table of Content

16 December 2010 Volume 24 Issue 6

  

Articles

Establishment and morphological assessment of the T-cell immune deficiency  mouse model with facial nerve axotomy

QUAN Shi-ming1, PENG Ben-gang1, GAO Zhi-qiang2

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  5-9. 

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Objective    To establish a stable and reliable T-cell immune deficiency mouse model with facial nerve axotomy by the application and assessment with morphological methods  on the immune deficiency mouse with facial nerve transection, so as to provide an experimental foundation for revealing the latent neuroimmunological mechanism of traumatic facial paralysis. Methods    The T-cell deficiency mice were subjected to a right facial nerve axotomy. Fluorogold retrotracer was used at a designated time. Two weeks after the operation, the slices of the brain stem were collected and the facial moto-neurons were observed and counted. Also, the injured facial nerve of axotomy nude mice was assessed with osmic acid staining. Results     All the mice presented typical facial paralysis after the transection of the facial nerve. Remarkable degenerations were observed in the distal end of the transected facial nerve on the 14th day after the operation. There was different status among the motoneurons in the facial nuclus, such as healthful, injured or dead. Significant difference in the number of facial moto-neurons between the nude mouse group and the wild type mouse group was noticed. Conclusion    The T-cell immune deficiency mouse model with facial nerve axotomy is effectiveand feasible. It provides an experimental foundation for revealing the latent neuroimmunological mechanism centering on T cell behavior of the pathogenesis and progression of facial nerve trauma.

Surgical outcomes of different types of  tympanosclerosis(40 cases report)

LIN Jun， SHEN Fan， LI Rui-yu， YE Qing

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  10-12. 

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Objective    To study the relationship between the type of preoperative hearing loss and the site of tympanosclerosis, and analyze  the effect of our surgical protocol for patients. Methods    The preoperative features, sclerosis focus detected  during surgery and hearing levels after surgery on tympanosclerosis were retrospectively summed up for 40 patients in our hospital from October 2005 to December 2009． Results    While attic and the incudostapedial joint involvement are most frequently seen in conductivetype hearing loss, mixed type hearing loss isolated promontorium and involvement of the incudostapedial joint and around stapes are not seen.Postop outcome was found to be 40% in the patients with an air-bone gap between 0-20 dB.The best hearing result belonged to type 1 patients. Cases in which the stapes footplate was fixated had the worst result in terms of hearing. Conclusion    There is a direct relationship between the type of preoperative hearing loss and the site of tympanosclerosis. Surgery is the main method for tympanosclerosis．The operation should be adapted to different areas and degrees of the sclerosis focus.

FK506 as antagonist to ototoxicity of Gentamycin

WANG Xiao1, JU Hong-shuang2, LIANG Gui-ling1, YAN Yong-hong1, SU Mei1

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  13-16. 

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Objective    To investigate the effects of FK506 to antagonize ototoxicity of Gentamycin. Methods   The gentamycin group and the groups of gentamycin plus different doses of FK506 (1mg, 2mg) were set up.  Then, the auditory brainstem response (ABR)  threshold was measured to explore the changes in hearing function. Cochlear preparations were stained with SDH to observe morphological changes. Results    Auditory data and morphological changes demonstrated significant differences between the gentamycin group and the groups of FK506 (P<0.05). FK506 could reduce the damages of gentamycin in the cochlea. Conclusion    Based on the experiment, FK506 can relieve the ototoxicity induced by gentamycin.

Clinical analysis of 36 benign paroxysmal positional vertigo patients treated with positional maneuver

LIU Jing-bo, LIU Jian-zhi, HUANG Jian-min

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  17-19. 

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Objective     To assess the therapeutic effect of positional maneuver in the treatment of benign paroxysmal positional vertigo (BPPV). Methods     Thirty-six  BPPV cases  diagnosed on the basis of the Dix Hallpike test and roll-rock test were reviewed. All of the patients were treated with the Epley (canalith repositioning) maneuver, Semont (liberatory) maneuver or Barbecue maneuver.  The therapeutic effects were evaluated. Results    Thirty-three BPPV cases  caused by lesion of the posterior semicicular canal were treated with the Epley or Semont  maneuver. The effective rate in this subgroup was 93.9%. The other 3 cases caused by lesion of horizontal semicircular canal were treated with the Barbecue maneuver and symptoms improved after the treatment. Conclusions     Positional maneuver is a simple, safe and effective way to treat benign paroxysmal positional vertigo. The procedures should be recommended.

Determination of MDA level， ADA activity and SOD activity in the polyp  and serum of patients with nasal polyps

ZHANG Yan，LI Gui-fang, REN Xiu-min, DUAN Nai-chao, YANG Yan-zhong

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  24-26. 

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Objective     To determine the MDA level, ADA and SOD activities and to explore their correlations in the polyp and serum of nasal polyp patients. Methods     The activity of ADA, SOD and MDA level of specimens and serum were measured with the method of chromatometry, and the polyp and serum of the experiment group were obtained from 24 patients with nasal polyp. The control specimens of the inferior turbinate mucosa and serum were acquired from 20 patients with deflection of the nasal septum. Results     ①The level of MDA and activity of ADA in the polyp and serum of nasal polyp patients were remarkably higher than those in the control group (P<0.01). The　activity-of-SOD-in-the polyp-and-serum-of-nasal-polyp-patients-were remarkably lower than those in the control group (P<0.01). ②There was a positive correlation between the NP group and the control group of MDA and ADA in tissues and serum（0<r<1, P<0.01）. There was an inverse correlation between the NP group and the control group of MDA and SOD in tissues and serum（-1<r<0, P<0.05）. Conclusion     The ability of removing free radicals descends and lipid peroxidation reaction is activated  in  patients with  NP, which hints that metabolic disorder of free radicals is one  pathogenesis of NP, and thereby, it can provide theoretical  proof for curing and preventing NP.

Volume sinus osteomas： clinical analysis and operative method in 21 cases

ZHENG Kuan-yi1, LI Zhi-feng1, SHI Guang-gang2, YANG Ming2

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  27-28. 

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Objective    To explore the clinical characteristic and surgery method for frontal sinus osteoma. Methods     Based on the volume and position of the tumor body, 21 cases of volume sinus osteoma were removed en-nose, ex-nose or en-and ex-nose jointly. Results    Followed up for 1 to 3 years post-operative, headache symptom disappeared, and no osteoma relapsed. Conclusion     Different operative routes based on the volume and position of the tumor are convenient and  helpful in reducing operative complications.

Therapeutic effect of endoscopic sinus surgery on rhinopharyngocele  with an image navigation system

CHEN Li-yan1, ZHOU Lu-sheng2, ZHANG Hua3, SONG Xi-cheng3

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  29-30. 

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Objective    To discuss the methodology and advantages of endoscopic sinus surgery on rhinopharyngocele with an image navigation system. Methods    4 patients with rhinopharyngocele underwent operations. All surgical procedures were done with general anesthesia， and fidelity positioning was done using a navigation system. The probe or suction unit was calibrated when needed. The exact position and margin of rhinopharyngocele was judged and fully removed with the help of endoscope and navigation system. Results     All were accurately located and removed with minimal trauma,and no complications occurred. Conclusion     A navigation system in combination with sinus endoscope can help locate rhinopharyngocele with accurate location and minimal trauma， increase curative effect and avoide complications.

Treatment of chronic sinusitis with endoscopic sinus surgery in elderly patients

HE Zhi-qiang，SHEN Fan

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  31-32. 

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Objective    To study the treatment effect of endoscopic sinus surgery (ESS) in elderly patients with chronic sinusitis. Methods    125 patients above 60 years age with chronic sinusitis were treated by endoscopic sinus surgery. Results    125 patients were interviewed with a follow-up of six months to one year post-operatively.Based on the assessment standards, theⅠ～Ⅲ type effect had a decreased tendency, and the 3rd of Ⅱ stage and the Ⅲ stage effects were poor. Conclusion    Endoscopic sinus surgery is effective for elderly patients with chronic sinusitis,its efficacy is closely related with clinical classification of the stage.

Rhinogenous headache related to abnormal anatomy of nasal cavity and treatment with nasal endoscopic surgery

CHEN Ying, DENG Ke-bin, ZHANG Li-ya, LIN You-ping

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  33-35. 

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Objective    To explore the pathogenesis, diagnosis and treatment of rhinogenous headache with absence of sinusitis, and the headache severity relationship to anatomical factors.  Method    48 cases were divided into two groups: A group (23 cases) with deviated nasal septum might have the abnormality of ostiomeatal complex (OMC)，a simple abnormality of OMC were observed in B group(25 cases) . The abnormal anatomical structure was resected or corrected by nasal endoscopy. The severity and improvement of headache were estimated with the visual analogue scale (VAS). Results    The headache severity of group A was significantly higher than that of group B (P<0.05). There was no significant difference in the two groups in therapeutic effect by endoscopic surgery (P>0.05). Conclusion     Endoscopic surgery is an effect method for rhinogenous headache with absence of sinusitis. Nasal septum deviation contributes to the severity of headache. It is important in treatment of correcting the complex abnormal anatomical structure.

Relationship between atopic factors and asthma and combined allergic rhinitis and asthma syndrome in children

BAO Ai-chun1, GONG Qi1, SHI Kui1, SUN Zhen-feng2, DONG Pin2

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  36-38. 

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Objective    To discuss the role of atopic factors of children on the development process from simple allergic rhinitis to bronchial asthma combined allergic rhinitis. Methods     One hundred and ten children with allergy rhinitis and combined allergic rhinitis and asthma syndrome (CARAS) were enrolled in this study.  The atopic factors for statistics, including personal and family allergen history and allergic dermatitis history were analyzed. Results    Among the 110 cases of AR surveyed, 26 cases were diagnosed as CARAS. There were significant differences in the influence of personal and family allergen history and allergic dermatitis history in the CARAS and simple allergic rhinitis groups. Conclusion    Atopic  status of children is a risk factor of the development of allergic  rhinitis  towards CARAS. The more positive number of allergic dermatitis history and personal and family allergen history, the more chance of development of allergic rhinitis towards CARAS.

Clinical study of cetuximab combined with post-operative concurrent  chemo-radiotherapy on recurrent advanced squamous cell-carcinoma of the head and neck

YU Zi-wei, DONG Pin, PANG Zheng

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  44-46. 

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Objective    To evaluate the clinical efficacy of cetuximab combined with concurrent chemo-radiotherapy on recurrent advanced squamous cell carcinoma of the head and neck. Methods    6 patients with recurrent advanced head and neck carcinoma，including 2 larnyngeal carcinoma, 1 hypopharyngeal carcinoma, 1 hypopharyngeal carcinoma with lung metastasis and 2 stomal recurrence, were treated with cetuximab combined with postoperative radiotherapy and chemotherapy. Cetuximab was administered at an initial dose of 400mg/m2 in the first week followed by weekly injection of 250mg/m2. All the patients received a total dose of 60Gyradiation(2Gy per fraction, 5 fractions per week ) and concurrent chemotherapy(cisplatin 80mg/m2 d1 and 5-Fu 800mg/m2 per week with 120 hour continuous intravenous injection). Results    All the patients completed the designated treatment. The primary side effects consisted of acne-like rash, stomatitis, and asthenia. All patients survived after 10 months of median followup time, and no progression and metastasis occurred. Conclusion     Cetuximab combined with postoperative concurrent chemoradiotherapy is efficient and safe for the management of recurrent advanced carcinoma of head and neck, however, a further largescale clinical trial is necessary.

Comparison of radiofrequency ablation tonsillotomy versus  standard tonsillectomy for OSAHS child patients

HOU Dong-ming, YANG Jun, CAO Rong-ping, MENG Guo-zhen, WANG Zhen-tao, MA Yan

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  47-49. 

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Objective     To explore the advantages of radiofrequency ablation tonsillotomy for child obstructive sleep apnea hypopnea syndrome(OSAHS). Methods    The operation time, blood loss, post-operative pain, and the days in hospital in the radiofrequency ablation tonsillotomy group and the standard tonsillectomy group of OSAHS child patients with tonsils hypertrophy were evaluated. Results    The operation time, blood loss, postoperative pain, and the days in hospital were significantly less (P<0.001) in the radiofrequency ablation group than in the tonsillectomy group.  Conclusion    Radiofrequency ablation tonsillotomy is a viable method for tonsils hypertrophy.

The clinical application of CT virtual bronchoscopy in the children  suspected with a bronchial foreign body

LI Li1, YUE Zhi-yong1, SHA Ying-hong2, YANG Jiang-fei3, HU Jun4, FAN Zhao-min1, WANG Hai-bo1

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  50. 

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Objective    To investigate the usefulness of CT virtual bronchoscopy(CTVB) in the evaluation and management of suspected foreign body aspiration and bronchopneumonia in children. Methods    From July 2008 to October 2009, 29 cases suspected with a foreign body in the bronchus, due to prolonged fever and repeated cough, were included in this study. CT virtual bronchoscopy was performed in all the patients. Then, rigid bronchoscopy images were obtained within 24hs. Results     With CTVB, foreign bodies were detected in 12 cases and bronchopneumonia were revealed in 17 cases. The result was consistent with rigid bronchoscopy except one sputum scab and one bronchus granulation was misdiagnosed as a foreign body. Conclusion    CT virtual bronchoscopy is sensitive and specific to confirm foreign body aspiration or bronchopneumonia in children.If the chest Xray is normal but an aspirated foreign body is suspected, CT virtual bronchoscopy should be considered to avoid unnecessary rigid bronchoscopy.

Clinical analysis of 1524 cases with tracheobronchial foreign body

YU Hai-qing， ZHAO Wei-xia

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  53-57. 

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Objective    To explore the experiences and lessons from peri-operative treatment of a tracheo-bronchial foreign body(TBFB)in children. Methods    Clinical data of 1524 children cases with tracheo-bronchial foreign bodies,  from Jan.1979 to Dec.2009 in Wengdeng Central Hospital of Weihai, were reviewed. Causes of serious peri-operative complications were analyzed and clinical experiences and lessons were summarized. Results    In 1524 cases, there were 4 death. The foreign bodies were removed from incisional openings in 5 cases and coughed out  in 32 cases . The rest were successfully taken out under a tracheoscope. Conclusion    Preoperative evaluation, emergency response protocol, timely and effective peri-operative treatment are the most important measures to reduce mortality and complications.

Percutaneous dilational tracheostomy in 30 cases

LIU Bo-song, LEI Chun-fang, YIN Hai, HUANG Xian, TAN Hai-tao

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  58. 

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Objective    To compare the clinical performance of percutaneous dilational tracheostomy(PDT) without the assistance of bronchoscopy and surgical tracheostomy(ST).  Methods     60 patients were divided into the PDT group and the control group (ST group)  and all the operations were performed in the ICU. Differences between the PDT and ST group were investigated, including operation time, size of incision, blood loss, incidence of pneumothorax and subcutaneous emphysema, tracheal esophageal fistula and symtomatic tracheal stenosis , wound infection, healing time, and changes of vital signs in the operation. Results     Compared with the control, PDT was more convenient and could significantly reduce the operation time and operative complications.  Conclusion     Under strict indications, percutaneous dilational tracheostomy can be widely applied in the clinic. Unlike traditional tracheostomy, it is simpler  and safer with shorter operative time, less trauma, and fewer complications.

Diagnosis and treatment of tracheo-bronchial foreign bodies in 686 children

DAI Wei-li， LIU Shi-lin， ZHANG Jie， LIU Wei-yi， ZHANG Ya-mei

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  61. 

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Objective    To explore the clinical characteristics，diagnosis, treatment，and proper time for surgery for foreign bodies in the airway of children. Methods    The clinical data of 686 children with tracheobronchial foreign bodies were retrospectively summarized. The foreign bodies in the airway were removed with a rigid tracheoscope，fiberbronchoscope or thoracotomy. Clinical outcomes were observed.  Results    Vegetative foreign bodies were found in 658 cases (95.9%)，while plastic foreign bodies in 7 and metal foreign bodies in 6 cases. The foreign bodies were removed in 660 patients with rigid tracheoscopy. 5 Fiberbronchoscopy and 1 thoracotomy were performed due to the foreign bodies residing in the basal segment of lowed lobe. In one case, the foreign body was coughed out.  Conclusion     Tracheo-bronchial foreign bodies is a common disease in early childhood. The progress is rapid and the surgery is risky.   Quick, accurate removal of the foreign body and intensive post-operative surveillance is required.

The combination of  fenestration with curettage in the treatment of  mandibular giant cystic ameloblastoma (12 cases)

WU Wen-yuan， LIN Po-shui， HONG Yu-ming， LIANG Zhen-yuan

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  64-66. 

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Objective    To explore the value of the combination of fenestration with curettage in the treatment of mandibular giant cystic ameloblastoma in order to preserve the shape and function of the mandibular. Methods    Twelve cases of mandibular giant cystic ameloblastoma were treated with fenestration and drainage. Duration of drainage ranged from 6 to 8 months, and the reduction of lesions was observed by X-ray film. All cases were treated with second-stage curettage when mandibular osteogenesis was stable. Results    All of the cases were cured. The mandibular rumas, sigmoid notch and coronoid process were remolded with integrity and continuity. Conclusion    The combination of fenestration with curettage in the treatment of mandibular giant cystic ameloblastoma does less damage to the tissue, and has shorter operation time, less postoperative complications, and less chance to have teeth, bones, lower alveolar nerves and vessels injured. For clinic doctors, it is worth learning.

Internal limiting membrane peeling combined with phacoemulsification for idiopathic macular holes

DU Xiu-juan, BI Hongsheng, WANG Xing-rong, DONG Wei-hong, CUI Yan, LI Hai-yan

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  67-69. 

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Objective    To evaluate the clinical efficacy of vitrectomy and internal limiting membrane peeling combined with phacoemulsification and IOL(Intraocular Lens Implantation) implantation for idiopathic macular holes with cataract. Methods    52 eyes were treated with phacoemulsification and vitrectomy. The internal limiting membrane was peeled and IOL was implanted. The eyes were filled with 20%C2F6 tamponade. Results    The closure of the macular hole was confirmed by OCT(Optical coherence tomography) in 51 eyes. Postoperative visual acuity of 46 eyes(88.5%) was improved. Early postoperative complications included corneal edema(5 eyes) ,macularedema(3 eyes) and transient increase of IOP (Intraocular pressure, 8 eyes). Late postoperative complications included secondary cataract in 3 eyes,which needed to be treated by Nd:YAG laser. Conclusion    As for idiopathic macular holes with cataract,vitrectomy and internal limiting membrane peeling combined with phacoemulsification is a secure, effective method with fewer postoperative complications.

Application of B ultrasound in diagnosis of choriodal hemangioma

WANG Jing-jie1，WEI Rui-li2，JIN Ling1

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  70. 

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Objective    To evaluate the application of ultrasonography, CT and MRI in the diagnosis of choroidal hemangioma. Methods    11 choroidal hemangioma patients confirmed clinically were reviewed. All cases were examined by ultrasound and 2 received extra fundus fluorescein angiography (FFA). CT scan was performed in 1 case and MRI in 4 cases. Results    Ultrasound showed shuttle-or olive-shaped, strong echo mass (n=11), homogeneous (n=8) or inhomogeneous mass (n=3). 1 case, on enhanced CT images,  showed thickening on the posterior funder wall of the eyeball,  with equal density  and marked enhancement. On MRI T1WI (n=4), 3 cases presented  equal  signal intensity, but one revealed high intensity. On T2WI, all 4 cases presented high signal intensity with marked enhancement. In 2 cases that underwent FFA,  antral hyperfluorescence in the early arterial phase, fluorescence leakage at the venous phase and hyperfluorescence in the late tumor stage was found.  Conclusions    B-ultrasonography,enhanced CT and MRI can help reach the diagnosis and locate choroidal hemangioma. B-ultrasound (+FFA) shows advantage in early  diagnosis while MRI imaging features in the diagnosis and differentiation.

General anesthesia with intra-operative wake-up test  in strabismus  surgery  in  70  patients

LIU Chun-ping1,GAO Fei2,JIAO Wan-zhen3, JI Jia-fu4

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  73-76. 

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Objective    To evaluate the feasibility and efficiency of the intraoperative wake-up test for strabismus surgery in teenagers. Methods    All 136 cases underwent general anesthesia and were divided into 2 groups. The first group had general anesthesia with intra-operative wakeup test, and the other had general anesthesia without the test. In the first group, operated muscles were first tightened with a slipknot. Then, the patient was awakened to examine the eye position. If the position was orthoptic, the suture was securely tied. Otherwise, general anesthesia was reinstalled and  the surgical procedures were repeated until the orthoptic position was achieved. The other group underwent surgery under general anesthesia with ketamine according to the preoperative assessment.  Results    (1)70 cases received intraoperative wake-up test. Among them, 65 reached orthoptic position when awakened while the procedures were repeated again in the other 5 cases to achieve the goal. (2)The success rate of the group with intra-operative wake-up test was 100% 1 week after the operation, which was significantly higher than the other group (92.4%, P=0.019). One year after the operation, the success rates of surgery in patients with and without intra-operative wake-up test were 93.7% and 87.1%, respectively. There was no significant difference among the two groups (P=0.214). Conclusion    General anesthesia with intra-operative wake-up test not only alleviates the pain of teenager in strabismus surgery, but also improvesthe success rate.

Treatment of traumatic optic neuropathy with methylprednisolone

ZHANG Ning， FAN Chuan-feng

JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY). 2010, 24(6):  77-78. 

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Objective    To compare the efficiency of methylprednisolone and dexamethasone in the treatment of traumatic optic neuropathy. Methods    58 cases(65 eyes) with traumatic optic neuropathy were randomly divided and the therapeutic effects were analyzed. In the treatment group, 31 eyes were treated with methylprednisolone,while 34 eyes were treated with dexamethasone in the control group. Results    There were significant differences between the two groups.In the methylprednisolone group, effective cures were 48.4% while the control was 29.432%(P<0.05). Conclusion    Methylprednisolone is better than dexamethasone in the treatment of traumatic optic neuropathy.