Eosinophilic chronic rhinosinusitis (eCRS), an intractable type of sinusitis that recurs easily after endoscopic sinus surgery, for inclusion is designated as an intractable disease by the Japanese Ministry of Health, Labour, and Welfare (MHLW). An anti-IL-4 receptor alpha chain antibody (dupilumab, Dupixent^®) has been approved as a drug that is effective in treating eCRS, and is now covered by the national health insurance in Japan. However, the MHLW has issued a guideline for the optimal use of Dupixent^®, and appropriate use based on this guideline is required. The guideline suggests that Dupixent^® only be used for patients with chronic rhinosinusitis with nasal polyps (CRSwNP) who are insufficiently responsive to existing treatments, in whom the total bilateral nasal polyp score is ≥ 5. The nasal polyp score has been used as the primary endpoint in an international clinical trial of CRSwNP without a clear description, which has led to confusion. In this paper, we provide a clear overview of the nasal polyp score criteria and discuss CT findings that may be useful for the diagnosis of eCRS. We present the CT findings of a case with ethmoid sinus predominance, corresponding to a JESREC score of 2.

In case of ossicular chain malformations, the preoperatively predicted prognosis sometimes differs from the prognosis signaled by histopathology. Flexible adoption of operative procedures, such as type III or IV tympanoplasty, or stapes surgery is necessary. Performance of type IV tympanoplasty is rare and there are few reports of the use of this procedure. We analyzed three cases of ossicular malformations treated by type IV tympanoplasty. The malformations were classified as type I in all three cases, according to Funasaka classification. Hearing improvement was successfully obtained in all three cases. In all three cases, type IVi tympanoplasty was performed. Ossicular stability was considered as having been obtained by fixing the columella to the malleus and incus, and good hearing improvement was maintained. The findings on middle ear and temporal bone CT before surgery are useful to determine the surgical procedures; the findings allow the surgical strategy to be predicted to some extent. However, there are some deformities that cannot be detected by CT, and the final decision on the procedure depends on the surgical findings. We think flexible adoption of surgical procedures and acquisition of informed consent from the patients are important.

Varicella is an acute infectious disease caused by the varicella-zoster virus. Most people are infected in childhood, before 10 years of age. However, a recent survey reported that the age of onset of varicella has shifted from young children to older children and adults. Varicella developing in adults tends to be more severe than that in children, and infection in patients with immunodeficiency due to medical treatments such as corticosteroids and chemotherapy is often fatal. Herein, we report an adult case of varicella with polyneuropathy.

The complication that was most associated with the QOL in this patient was dysphagia. Glossopharyngeal nerve paralysis impaired pharyngeal perception, hypoglossal nerve paralysis impaired passage of a food bolus into the pharynx, and vagus nerve paralysis caused glottic insufficiency and diminished pharyngeal muscle contraction, in addition to weakening the laryngeal sphincter function. It is considered that such patients are at a higher risk of dysphagia and aspiration because of impairment of the laryngeal reflex caused by sensory deficiency of the larynx. Due to the impaired swallowing function, the patient developed aspiration pneumonia while hospitalized, despite receiving direct swallowing training. Among the patients with cranial nerve palsies, it has been reported that vagus nerve disorder is associated with a poorer prognosis than disorder of other nerves. Varicella is not commonly associated with multiple cranial nerve palsies, but when cranial neuropathy does occur as a complication, it could significantly reduce a patient’s QOL; therefore, it is necessary to closely monitor adult patients developing varicella.

Transmastoid decompression of the facial nerve, one of the treatments used for severe peripheral facial palsy, remains a controversial treatment modality. In this report, we reveal that there was no significant correlation between the enhancing portion of the lesion on MRI and the rate of progression of the palsy, except for the case of the enhancement of the horizontal segment. The hypothesis that “Among patients undergoing transmastoid decompression, cases showing enhancement of the labyrinthine segment on preoperative MRI would show worsening of the paralysis postoperatively as compared to patients who do not show such enhancement on MRI” could not be proven. Additionally, there was also no relationship between lesion enhancement observed on MRI, except for enhancement of the horizontal segment, and the inoperative findings (P=0.048). Based on these perspectives, we assume that transmastoid decompression, without decompression of the labyrinthine segment or fundus of the internal acoustic meatus may be effective for the treatment of severe peripheral facial nerve palsy.

Intratympanic membrane cholesteatoma is a rarely encountered disease in patients without a history of tympanic membrane trauma. Herein, we report a case of intratympanic membrane cholesteatoma. A 2-year-old male infant with a white, raised lesion on the left tympanic membrane was brought to our hospital. We endoscopically resected the lesion under general anesthesia. Histopathologically, the lesion was diagnosed as a intratympanic membrane cholesteatoma. The postoperative course was favorable, without recurrence. The usual treatment for intratympanic membrane cholesteatoma is surgical resection. Therefore, the relationship between the tympanic membrane and the middle ear cavity should be examined to select the optimal surgical procedure.

This is the first report, to the best of our knowledge, of a laryngeal lesion in a patient with Crohn’s disease; the lesion led to laryngeal stenosis and dysphagia. The patient, a 66-year-old woman, who had been diagnosed as having Crohn’s disease and was in remission, visited the gastroenterology department of our hospital with the chief complaint of difficulty in swallowing. Endoscopic evaluation led to the suspicion of laryngeal stenosis, and the subject was referred to our department. Laryngeal endoscopy showed the presence of a sub-circumferential film-like adhesion extending from the epiglottis to the pharyngeal cavity. Incidentally, as per her medical record, an upper gastrointestinal tract endoscopy performed 10 years earlier had also revealed the same lesion. Since the lesion did not appear to have worsened since it was first observed 10 years ago, and laryngeal endoscopy and simple cervical computed tomography did not reveal any obvious respiratory stenosis, conservative treatment, rather than surgery, was selected, and the laryngeal stenosis has not worsened since. Although this is a rare condition, we plan to collect more data on such cases and investigate the appropriate methods of treatment.

Spindle cell lipoma (SCL) is a relatively rare subtype of lipoma, that arises predominantly in the subcutaneous tissue of the back of the neck, shoulder, and back. We report a case of a giant SCL arising from the lateral neck. A 56-year-old man presented with a right cervical mass, that had gradually increased in size over a period of about three years. On examination, the tumor was found to measure 12 cm in maximum diameter. The preoperative diagnosis by needle biopsy was suspected liposarcoma, and we resected the tumor under general anesthesia. The biopsy skin was removed with the tumor, and extensive resection was performed. The histopathological diagnosis was SCL, and the tumor has not recurred until now, 2 years after the surgery. SCL is removed by marginal resection and does not recur, according to reports. In some previous reports, as in this case, extensive resection was performed on account of a preoperative diagnosis of suspected liposarcoma. Thus, to avoid extensive resection, it is important to make a precise diagnosis of SCL before operation. In the case reported herein, we had difficulty in confirming the diagnosis, because of the tumor was located at an atypical site and our pathologist had no experience in diagnosing this tumor. Thus, the diagnosis of SCL should be borne in mind in patients presenting with atypical head and neck fatty tumors.

Calcifying epithelioma (CE), also called pilomatricoma, is a benign tumor arising from the hair matrix cells and usually occurs in children and young adults. Approximately 10% of all CEs occur in the head and neck region. The tumor is usually treated by dermatologists or plastic surgeons, and otolaryngologists may not be familiar with CE.

We report three cases of CE, one each in the lateral neck, posterior neck, and infra-auricular region. The patients were 5, 11 and 23 years old; two were female, while the third was a male. The tumors ranged in size from 6×10 mm to 15×17 mm. On fine-needle aspiration (FNA) cytology, the findings were suspicious of malignancy in 2 cases. The presence of basophilic cells could cause CE to be misdiagnosed as a malignant tumor. The final diagnosis should be made on the excised specimen.

We reviewed the data of 15 previously reported cases, along with those of our 3 cases of CE reported herein, that were managed by an otorhinolaryngologist in Japan, and found that patients ranged in age from 1 to 25 years and the most frequently involved site was the parotid region. While ultrasonography, CT and MRI are also useful adjuntive tools for the diagnosis of CE, attention must be paid to the fact that CE could be misdiagnosed by FNA cytology as a malignant tumor (or false-positive result). Out of the 15 previously reported cases, 3 were preoperatively misdiagnosed as malignancy. All the patients with CE had an uneventful course and none showed recurrence.

Cases of impalement injuries in the head and neck region, such as injuries caused by toothbrush penetration of the oropharyngeal area, are often encountered in the field of pediatric medicine, although facial injuries are relatively rare. In most cases, a part of the object remains lodged in the patient, because the depth of penetration cannot be gauged accurately from the external appearance of the skin or oropharyngeal membrane. Therefore, prompt diagnosis and appropriate treatment are essential to prevent airway obstruction or severe infection which are likely to occur sooner or later depending on the severity and site of the injury. Herein, we present a case of impalement injury caused by the rib of a parasol penetrating the right auricle through to the contralateral submandibular region.

A 73-year-old male patient was struck on his right auricle by the rib of a parasol that was blown away by the wind. He extracted the object by himself, but presented with bleeding from his injured auricle and mouth. Examination revealed an approximately 1-cm laceration on his right auricle, a small hematoma under the right pharyngeal membrane, and slight damage to the pharyngeal mucosa. While computed tomography (CT) did not confirm the presence of a foreign body, it revealed subcutaneous emphysema extending from the auricle to the contralateral submandibular region, indicating the path taken by the penetrating body. Although the patient complained only of the pain caused by his injury, he was admitted for antibiotic therapy, considering the likelihood of his condition worsening. He developed a transient swelling of the left submandibular region and a hematoma development under the laryngeal membrane, but after seven days of conservative treatment, the inflammation improved, and the patient was discharged home.

In general, foreign bodies showing deep tissue penetration as in the present case, should be removed under general anesthesia to avoid major bleeding, although our patient had extracted the object by himself without suffering any complications. In addition, intravenous antibiotic treatment should be administered during hospitalization to prevent infection in cases with deep tissue penetration by a foreign body.

A transdermal patch containing emedastine difumarate (ALLESAGA^® TAPE) was the first transdermal drug delivery system developed for allergic rhinitis, including Japanese cedar pollinosis, in Japan. However, only few studies have been conducted to determine its clinical efficacy, usability and satisfaction level of the patients.

We prospectively evaluated the efficacy of emedastine patch treatment in 41 patients with Japanese cedar pollinosis.

The efficacy of treatment was better in those who were treated prior to massive pollen dispersal than in those who were treated after massive pollen dispersal. More than 60% of the patients were satisfied with the emedastine patch treatment, and more than 70% of the patients wished to continue the treatment. In addition, the medication adherence rate was more than 90%.

The plasma concentrations of medications increase more slowly with dermal patch formulations than with oral formulations. Owing to its slow effect on the clinical status, the application of emedastine patch treatment in patients with Japanese cedar pollinosis may need to be started prior to massive pollen dispersal for obtaining greater efficacy.

Purpose: The use of peripherally inserted central venous catheters (PICCs) has increased recently; several reports have indicated that they can be easily and safely used in patients with various diseases. However, there are few reports on the use of PICCs in patients with head and neck cancer. This study was aimed at evaluating the safety and feasibility of use of PICCs in patients with head and neck cancer.

Materials and Methods: We retrospectively analyzed the data of 118 PICC insertions in 85 patients with head and neck cancer from January 2014 to December 2017. The PICCs have been placed under ultrasound guidance in all cases.

Results: The PICC puncture success rate was 95.2%. Catheter-related bloodstream infection occurred in four cases. The most common complication necessitating PICC removal was suspected catheter-related bloodstream infection (24 cases). All cases with confirmed and suspected catheter-related bloodstream infection improved with administration of antimicrobial agents. Phlebitis occurred in five cases, in all of whom the PICC placement had been made via an antecubital vein; the condition improved without treatment in all five cases. Deep vein thrombosis occurred in two cases, both of which improved with oral anticoagulant therapy.

Conclusion: This study demonstrated that the complications associated with ultrasound-guided PICC insertion are manageable, and improve with conservative treatment in the majority of cases. Therefore, use of PICCs may be considered for easy and safe central venous access in patients with head and neck cancer, because the insertion success rate was acceptable.