Allergic rhinitis (AR) is a type I hypersensitivity reaction of the nasal mucosa in response to inhaled aeroallergens, and manifests with clinical symptoms such as watery rhinorrhea, nasal congestion, itching, and sneezing. Serum antigen-specific IgE (sIgE) measurements and a skin test (ST) against aeroallergens have been routinely employed to diagnose AR. Individuals exhibiting symptoms of AR without a positive ST or elevated serum sIgE have been diagnosed as non-AR cases. However, the concept of local AR (LAR) has recently been reported as a clinical entity, mainly and initially in Europe. LAR is characterized by the symptoms of AR without evidence of systemic atopy as assessed by the ST and/or measurement of the serum sIgE. The diagnosis of LAR should be rationally based on the detection of sIgE in the nasal secretions or mucosa, and is now practically diagnosed by a nasal allergen provocation test (NAPT). LAR is a stable phenotype and does not represent the initial stage of conventional AR; however, it is characterized by moderate to severe nasal symptoms, marked impairment of the quality of life (QOL) and rapid progression to symptom worsening. It should also be noted that LAR is often complicated by other atopic diseases, such as atopic asthma and/or conventional AR. While no attention was paid to LAR in Japan for a long time, we reported LAR in Japan this year, for the first time, based on our clinical and experimental studies. According to our study, LAR is supposed to exist with the sensitization by house dust mites or Japanese cedar pollen. This article presents a review about LAR, including the history, concept, diagnostic criteria and therapeutic options, in reference to recent updated publications, including our published study.

We report a case of extramedullary plasmacytoma in nasal cavity. A 47-year-old male presented to us with a 3-month history of right nasal obstruction and repeated bleeding from the nose. Nasal endoscopic examination showed a reddish and easily bleeding tumor, about 3 cm in diameter, in the right nasal cavity. Histologic examination of biopsy specimens obtained from the lesion revealed extramedullary plasmacytoma with κ type IgA. Radiation therapy at a total dose of 40 Gy was undertaken, and the nasal tumor disappeared. However, about 3 years after this treatment, the patient was diagnosed as having multiple myeloma with involvement of the ulna, sternum and tibias. We treated the patient with several cycles of chemotherapy including bortezomib or melphalan, followed by autologous peripheral blood stem cell transplantation. As at the time of submission of this case report, the patient remains alive, with stable disease.

Extramedullary plasmacytoma is characterized by malignant transformation of plasma cells. Only 5 cases with extramedullary plasmacytoma in the nasal cavity that went on to develop multiple myeloma on a subsequent date have been reported. The median period from the end of treatment to the development of multiple myeloma was 32 months in the 5 cases. Therefore, long-term follow-up in collaboration with a hematologist is needed for patients diagnosed as having nasal extramedullary plasmacytoma.

Deep neck infection is a serious and potentially life-threatening infection that spreads in the spaces surrounded by the cervical fasciae. It is divided into 3 stages, lymphadenitis, cellulitis, and abscess. Most cases of masticator space abscess are caused by odontogenic inflammation. The masticator space includes the mandibular bone and the masticatory muscles (masseter muscle, inner and outer pterygoid muscles, temporal muscle), neurovascular bundles, adipose tissue, and loose connective tissue. However, in our present case, the abscess had no obvious odontogenic origin.

A 78-year-old woman visited us complaining of pain around the temporomandibular joint and trismus. Contrast-enhanced CT revealed peritonsillar abscess on the right side, extending from the nasopharyngeal level to the masticator space. Because oral incision and drainage was difficult on the first day due to the presence of trismus, we drained the abscess nasally via a rigid nasal endoscope. With the improvement of the trismus thereafter, oral incision and drainage could be performed from the second day onward. Peritonsillar abscess is a common disease, but could be severe; therefore quick and accurate treatment is necessary.

Rosai-Dorfman disease (RDD) is a rare type of histiocytosis that was first reported as sinus histiocytosis with massive lymphadenopathy by Rosai and Dorfman in 1969. We report the case of a 77-year-old man who presented with a 2-month history of left parotid enlargement. Blood examination showed an elevated serum level of soluble interleukin-2 receptor. Fine needle aspiration cytology of the left parotid gland nodule showed many lymphocytes without atypia. Therefore, we suspected of malignant lymphoma and performed left partial parotidectomy for obtaining a definitive diagnosis. The histopathologic diagnosis was RDD. Because the patient had no symptoms or vital organ involvement, he has been under close observation for 15 months since.

The preoperative diagnosis of RDD is difficult, but if the characteristic finding of emperipolesis can be recognized in fine needle aspiration cytology, it may be possible to diagnose RDD before surgery. In patients with a histopathologic diagnosis of RDD, it is necessary to perform a full body search at regular intervals to determine whether treatment is necessary, because the prognosis is poor in some cases.

Descending necrotizing mediastinitis (DNM) is rare; the disease refers to head and neck inflammation descending to the mediastinum. Treatments include systemic antibiotics and surgery to drain the neck and mediastinum. Although many new antibiotics are available, as are novel surgical devices, DNM can be fatal, and early and appropriate treatment is critical to stop the disease progression. Even with appropriate treatment, some patients show progression or disease recurrence. We encountered three patients with DNM at our hospital. One was treated by primary mediastinal surgery, followed by intermittent drainage using a Penrose drain. Five days later, the patient developed recurrence, necessitating reoperation. In the second case, continuous drainage after primary mediastinal surgery was performed using pleated silicon drains, and there was no recurrence. The internal pleats of such drains maintain the lumen, and they are soft, making them suitable for continuous drainage of the mediastinum. The third case initially had a neck abscess, and DNM developed 4 days after neck surgery. Drainage similar to that in the second case was adopted, with a good treatment outcome. Continuous drainage using a pleated silicon drain can effectively suppress recurrence of DNM.

Metastasis to the thyroid is very rare, especially in patients with cancer of the digestive tract. We report the case of a 71-year-old woman with primary thoracic esophageal carcinoma who presented with a metastatic mass in the right lobe of the thyroid gland. The patient, who had been diagnosed as having thoracic esophageal carcinoma two years earlier at another hospital, had shown complete response to chemoradiotherapy. However, she subsequently developed a local recurrence and was referred to our hospital. We administered photodynamic therapy and achieved good control of the local recurrence. However, a follow-up imaging examination revealed a mass in the right lobe of the thyroid gland. In consultation with the Department of Gastroenterology, we carried out fine-needle aspiration cytology. The cytological findings were categorized as “Class V”, however, no definitive diagnosis could be made. Since we also detected a cervical lymphadenopathy at the same time, total thyroidectomy with neck dissection (Levels II-IV) was performed. The final histopathological diagnosis of the thyroid mass was “squamous cell carcinoma,” the histological features being consistent with those of the primary thoracic esophageal carcinoma. No evidence of recurrence has been found until now, 14 months after the surgery. Based on previous literature, the prognosis of esophageal carcinoma patients with metastasis to the thyroid gland is so poor that close follow-up to detect early recurrence is highly recommended.

The American Joint Cancer Commission (AJCC) and Union for International Cancer Control (UICC) 8th Edition modified their TNM Staging Manual by introducing a staging rule for carcinoma of unknown primary in the head and neck (CUP). Histopathological examination of the lymph node is necessary for the diagnosis of CUP to determine viral involvement in the case of nasopharyngeal or oropharyngeal cancer. However, an open biopsy should be avoided to prevent tumor cell dissemination. Herein, we reported a case of neck mass which was diagnosed as a CUP, potentially from oropharyngeal cancer, by core needle biopsy (CNB).

A 56-year-old man presented to us with a cervical mass. We suspected parotid gland cancer, as the mass was in the vincinity of the parotid gland, and there was no evident pharyngolaryngeal lesion. When we performed CNB for histological confirmation of the diagnosis of parotid gland cancer, we found a 100% positive result for HPV. We performed imaging examinations and biopsy of the left tonsil, but failed to identify the primary tumor. We decided to label the case as one of CUP HPV-positive T0N3M0, and administered CRT. Patients with HPV-positive tumors are known to show a good response to chemoradiotherapy, as did our patient too, and the CR continues to be sustained. If a cervical lymph node is unresectable, CNB may be attempted for histological diagnosis. The importance of CNB for the diagnosis of CUP is discussed.

The abscopal effect is rarely seen with radiotherapy, where local radiotherapy is associated with the regression of metastatic tumors that are distant from the irradiated site.

Nivolumab is an immunologic checkpoint inhibitor that blocks the PD-1 expressed on T cells.

We present the case of a patient treated with nivolumab in whom an abscopal effect was observed. A 48-year-old male patient was diagnosed as having tongue cancer. He received local excision of the ­primary lesion and neck dissection, followed by concurrent chemoradiotherapy. He remained disease-free for 11 months, when CT revealed a new pulmonary nodule and malignant pleural effusion. For the recurrent disease, the patient was initiated on treatment with nivolumab, and after five cycles, a repeat CT showed progression of the pulmonary nodule and pleural effusion and additional mediastinal lymph node metastasis, and a bone metastasis in the twelfth thoracic spine. The patient was initiated on palliative radiotherapy to treat the back pain caused by the spinal metastasis. After this radiotherapy, CT showed a reduction also in the size of the pulmonary nodule and pleural effusion, and stable sizes of the mediastinal metastatic lymph nodes. Remarkably, lesions in areas not targeted by the radiotherapy had also regressed. He was treated with five additional cycles of nivolumab, after which a CT showed a good response at these sites.

The abscopal effect may be mediated by activation of the immune system. The mechanism of the effect caused by radiotherapy and immune checkpoint inhibitors is gradually becoming clear. Combining immunotherapy and radiotherapy may improve the oncologic outcomes in cases of head and neck cancer.

Pseudoaneurysms are critical and acute. Carotid artery pseudoaneurysms are rare, and cases of tuberculosis aneurysm are extremely rare. We report the case of a 55-year-old male patient who presented with a common carotid artery pseudoaneurysm complicating tuberculous lymphadenitis. He received open surgery for the lymph node tuberculosis and carotid pseudoaneurysm, and antibiotic therapy for tuberculosis. The postoperative course was uneventful and the patient recovered and lived in good health afterwards. Because extrapulmonary tuberculous pseudoaneurysms are clinically similar to other types of infected aneurysms, infection by Mycobacterium tuberculosis should always be suspected at the initial diagnosis. Because a tuberculous pseudoaneurysm arises acutely and can be critical, prompt diagnosis and early treatment are important.

Laryngeal sarcoidosis is rare, and reports of recurrences after treatment are even rarer. A 49-year-old Japanese female patient visited our clinic with a 7-day history of dysphagia. Her medical history included sarcoidosis involving the cervical lymph nodes. Endoscopic examination revealed a diffusely swollen epiglottis and bilateral edema of the arytenoids. Corticosteroids and antibiotics were administered, but the laryngeal edema did not subside. Contrast-enhanced computed tomography imaging revealed bilateral low-density areas in the arytenoids. Therefore, we performed bilateral arytenoid biopsy under direct laryngoscopic guidance. The histopathology showed non-caseating epithelioid cell granulomas with moderate to severe chronic inflammatory infiltration; based on these findings, we diagnosed the patient as having laryngeal sarcoidosis. While the laryngeal edema did not recur for several months, arytenoid edema recurred nine months after the systemic steroid therapy. The patient’s medical history of sarcoidosis of other organs, as well as the presentation of edema of a supraglottic lesion and histopathological findings of non-caseating epithelioid cell granulomas led us to make the diagnosis of laryngeal sarcoidosis again. Laryngeal sarcoidosis is an important consideration in the differential diagnosis of laryngeal edema, as its therapy and clinical course are different from those for other diseases that present with laryngeal edema. Cautious follow-up of patients diagnosed as having laryngeal sarcoidosis is needed, because in rare cases, the laryngeal edema can become worse over time even after therapy.