I reviewed the history of endolymphatic sac surgery, the most commonly performed surgical procedure for Meniere’s disease around the world. I also reviewed the current status of this procedure in Japan and its outcomes, as well as the outcomes at our institution, based on a systematic review.

Although there is a lack of high-quality studies on endolymphatic sac surgery at this time, many reports indicate that it is useful for controlling vertigo, at least in the short term.

With the advent of new imaging studies on endolymphatic hydrops called HYDROPS (hybrid of reversed image of positive endolymph signal and negative image of perilymph signal), I believe that Meniere’s disease will be more accurately diagnosed and properly treated by surgery in the future. In addition, I have also introduced new treatments and new surgical techniques. I am hopeful that in the future, endolymphatic sac surgery will progress to preventive surgery aimed at hearing preservation.

Middle ear neoplasms, including neurinomas, ceruminomas, carcinoids, glomus tumors, adenocarcinomas and squamous cell carcinomas, are relatively rare, and diagnosis and treatment are often difficult. Middle ear adenomas (MEAs) are even rarer, with few published reports of cases, and the classification and treatment of these tumors have not yet been established.

A 43-year-old man presented to us complaining of right aural fullness and auditory disturbance. His right tympanic membrane was swollen and white. A temporal-bone CT revealed a soft tissue shadow in the middle ear, with no evidence of destruction of the bone. The hearing level in his right ear was within normal range. We performed a right ear tympanoplasty for diagnosis and treatment. At first, we suspected middle ear cholesteatoma or chronic otitis media. However, intraoperatively, a solid tumor was found extending from the mesotympanum to the epitympanum, enfolding all of the auditory ossicles. We removed a part of the tumor to confirm the diagnosis. A frozen-section examination revealed the diagnosis of MEA. Immunohistochemical analysis of the tumor revealed evidence of neuroendocrine differentiation of the tumor, without any signs of malignancy. The patient underwent a second surgery for resection of the entire tumor, however, a residual tumor was left around the stapes. At the third operation, we used a CO₂ laser to cut the superstructure of the stapes to allow any residual tumor to be removed. The postoperative course was uneventful and the patient has shown no evidence of recurrence until the present, 12 months after the third operation.

We encountered a case of MEA that was difficult to diagnose before the surgery, and it also proved difficult to remove the tumor in its entirety. The tumor was located within the middle ear, with no evidence of bone destruction, so that there was little doubt about the diagnosis of MEA, mixed type. If the diagnosis of a middle ear tumor cannot be established prior to the surgery, sufficient imaging evaluation should be conducted before the surgery. Also, the surgical procedures adopted should be determined taking into consideration the clinical findings.

Malignant otitis externa (MOE), an invasive infection of the external auditory canal and skull base, typically occurs in elderly patients with diabetes mellitus. The most common causative agent is said to be Pseudomonas aeruginosa, but other species of bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), have been implicated. Common presenting symptoms of MOE include otalgia, otorrhea, aural fullness, and hearing loss. Facial paralysis may occur depending on the extent of progression of the disease. Herein, we report a patient with malignant otitis externa who presented with otorrhea and facial palsy.

An 86-year-old female patient with a history of diabetes mellitus, heart failure, and undergoing maintenance hemodialysis due to diabetic nephropathy presented with a history of otorrhea and otalgia. Her symptoms failed to improve despite treatment with cephem antibiotics and ofloxacin ear drops, and she developed left facial paralysis two weeks after the start of treatment. She was referred to a general hospital for computed tomographic imaging, which revealed thinning of the tegmental wall; therefore, the patient was referred to our hospital for further treatment. Pseudomonas aeruginosa was cultured from the otorrhea fluid. Based on the clinical course, we made the diagnosis of MOE. On day 4 of hospitalization, mastoidectomy was performed to establish drainage, remove granulation tissue from the middle ear, and obtain a specimen for detecting evidence of malignancy. After six weeks of intravenous antibiotic treatment, while her facial paralysis remained persistent, the otalgia and otorrhea resolved, with no signs of recurrence to date.

Antibiotic treatment is the standard treatment for MOE. If the patient fails to respond sufficiently to conservative treatments, surgical intervention should be considered. In the present case, surgery was performed 4 days after hospitalization, which led to prompt resolution of the otorrhea and otalgia.

External auditory canal cholesteatoma (EACC) is a rare disease, and the pathogenesis and optimal treatment method are not yet established. From January 2018 to July 2019, we performed transcanal endoscopic ear surgery (TEES) on 6 ears with EACC. The median age of the patients was 64 years, and the site of involvement was the inferior wall in 4 ears and both the inferior and anterior walls in 2 ears. According to Naim’s classification, 4 of the affected ears were classified as Stage III and the remaining 2 were classified as Stage IV. Of the 2 Stage IV cases, the disease extended to the temporomandibular joint in 1 case, and to the temporomandibular joint, eardrum, and tympanic cavity in the other. Underlying disease with microangiopathy was noted in 66% of the cases (4/6 ears) had (myocardial infarction, n = 1; dialysis for chronic renal failure, n = 1; administration of bisphosphonate, n = 1; subarachnoid hemorrhage and hypertension, n = 1). Therefore, from the perspective of wound healing, EACC requires minimally invasive surgery. Even in cases where the temporomandibular joint capsule was exposed, the anterior wall of the external auditory canal could be visualized because the endoscope had a wide field of view. In all patients, a dry and self-cleaning external auditory canal was found to be maintained at the time of the follow-up at 12 months. Our results suggest that TEES is useful for EACC.

I conducted a detailed examination of the prescription rates of antiallergic agents, including oral and nasal preparations, prescribed for patients with Japanese cedar pollinosis in 2016, when there was little cedar pollen in the air, and in 2019, when the atmospheric levels of cedar pollen were much higher.

The subject sample included 540 patients in 2016 and 1,170 patients in 2019, from whom data were obtained during the 8-week period from early February to late March.

In both years, approximately 98% of patients were prescribed oral agents, while the rate of prescription of nasal formulations was around 23%.

In both years, combined prescriptions for oral agents and nasal formulations were provided in descending order of one oral agent alone, two oral agents, and one oral agents with a nasal formulation; the rates were 54.8%, 21.9%, and 15.4% in 2016, and 38.7%, 35.6%, and 13.6% in 2019, respectively. Prescriptions of one oral agent most commonly included an antihistaminic agent, while prescriptions of two oral agents included an antihistamine agent combined with an antileukotriene agent. Three agents were also prescribed, but only to a small number of patients. In approximately 90% of cases, the prescribed nasal formulations were steroid nasal sprays. The agent prescribed was changed, or additional agents were given in approximately 25% of patients given multiple prescriptions due to insufficient effects.

I believe that the reason for the low rate of prescription of nasal formulations is the low acceptance rate of such preparations. The rate of prescriptions of two oral agents was higher in 2019 than in 2016, and more patients were prescribed antileukotriene agents, which I believe is due to the fact that there was a higher number of patients with relatively severe nasal symptoms.

Introduction: Rendu-Osler-Weber disease (Osler’s disease) is an autosomal-dominant genetic disease that is associated with peripheral vasodilatation and a tendency towards bleeding due to abnormal vascular wall formation. In the field of otolaryngology, we often encounter cases with recurrent and refractory nasal bleeding associated with this disease.

Case: The patient was a 44-year-old man who presented with the chief complaints of repeated epistaxis and anemia. Cerebral angiography was performed, and at the time of imaging of the right external carotid artery, a collection of abnormal blood vessels was found in the nasal septum, with the sphenopalatine artery as the feeding blood vessel.

Consideration: Endovascular treatment appears to be effective to reduce the frequency of epistaxis.

Since the symptoms of Osler’s disease are diverse, it would be desirable to refer the patient for screening tests in other departments rather than completing the diagnosis and scrutiny at the otolaryngology department alone.

Conclusion: Cerebral angiography for Osler’s disease revealed arteriovenous malformation (AVM) under the nasal septal mucosa, and we performed endovascular embolization.

Nose bleeding in a patient with Osler’s disease may be caused not only by peripheral vasodilation, but also by the presence of an arteriovenous malformations under the nasal mucosa.

Sarcoidosis is a multisystem inflammatory disease of unknown etiology, characterized histologically by the formation of non-caseating epithelioid cell granulomas in any part of the body. Lesions are most commonly found in the lungs, eyes, and skin, and rarely in the parotid gland.

We report a case of parotid gland sarcoidosis. A 45-year-old female patient was referred to our department with the chief complaint of pain behind the right ear. Her past medical history and family history were unremarkable. A mass lesion measuring approximately 20 mm in diameter was palpable just behind the right ear, with no evidence of facial nerve palsy. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) showed a contrast-enhancing mass with indistinct borders measuring 20 mm in diameter in the right parotid gland. Although fine-needle aspiration cytology showed only inflammatory findings, the imaging findings led to the suspicion of malignancy. Therefore, fine-needle biopsy and PET/CT were additionally performed. The PET showed abnormal accumulation in the right parotid gland, so that malignancy could not be ruled out; however, the fine-needle aspiration biopsy showed non-caseating epithelioid cell granulomas, and the imaging findings were also consistent with the diagnosis of parotid gland sarcoidosis. There were no obvious abnormalities in the lungs, heart, eyes, or skin, and the patient was finally diagnosed as having parotid gland sarcoidosis. Serum levels of angiotensin converting enzyme (ACE) and soluble IL-2 receptor were within normal range. The patient was initiated on oral steroid therapy, and the mass disappeared, without recurrence even after discontinuation of the steroid treatment.

In conclusion, although rare in patients presenting with parotid masses, it is necessary to bear in mind the possibility of sarcoidosis, even if the imaging findings lead to the suspicion of malignancy. Histopathological examination is important, especially in the absence of specific findings.

Introduction

The overall survival rate (OS) of head and neck carcinoma patients with resistance or intolerance to platinum agents had improved significantly with the introduction of immune checkpoint inhibitors (anti PD-1 antibody). At the same time, the proportion of patients developing immune-related adverse events (irAEs) and requiring sequential treatment is not negligible.

Subject and methods

The present study population included 42 patients, all of whom were treated with nivolumab at our institution from April 2017 to December 2019. We conducted a retrospective review of the patient data, to determine the OS, progression-free survival rate (PFS), overall response rate (ORR), and disease control rate (DCR) in the patients using the Kaplan-Meier method. Furthermore, we also determined the incidence/severity of irAE in accordance with the Common Terminology Criteria for Adverse Events Version (CTCAE) 4.0.

Results

The median of OS was 336 days, the 1-year OS was 49.9%, and the 2-year survival rate was 24.4%. The median PFS was 111 days, and the 1-year PFS was 17.1%. However, subgroup analysis of the patients classified by the histopathological category into the SCC group and non-SCC group revealed that while the median OS period and 1-year OS were 17.9 months and 53.2%, respectively, in the 30 cases of SCC, and 10.4 months and 41.7%, respectively, in the 12 cases of non-SCC group. There was 1 case of complete response, 5 cases of partial response, 13 cases of stable disease, and 21 cases of progressive disease. On the other hand, the ORR was 15%, and the DCR was 47.5%. Moreover, the appearance of irAE necessitated discontinuation of nivolumab in 8 cases.

Conclusion

① Although the efficacy of nivolumab was not significantly different from that reported by other authors, there was a tendency for a relative high proportion of patients to require treatment discontinuation because of the occurrence of irAE.

② There was one case of long survival as a result of prompt management of the irAE and continuation of nivolumab treatment.

Parapharyngeal space tumors are rarely encountered in clinical practice.

There are often few subjective symptoms, and in many cases, the tumors are progressive. In recent years, widespread use of imaging has led to an increase in the incidental diagnosis of these tumors.

Most parapharyngeal space tumors are benign, such as schwannoma and pleomorphic adenoma. On the other hand, recent reports have suggested that the tumors are malignant in 13% to 26% of the cases.

We encountered a case of lipoma with suspected malignant transformation. The tumor was located in the parapharyngeal space, was diagnosed as a liposarcoma by fine-needle aspiration, and surgery was performed. The postoperative histopathological diagnosis was benign lipoma. A precise preoperative diagnosis is necessary to determine the optimal surgical procedure in patients with a parapharyngeal tumor.

Since ectopic thyroid glands are usually located in the midline, cases of ectopic thyroid cancer occurring in the lateral neck are extremely rare. Ectopic thyroid carcinoma is a small carcinoma of the thyroid gland often diagnosed after the development of lymph node metastasis or distant metastasis, which is also very rare. In this article, we report a case of ectopic thyroid carcinoma arising from the lateral neck or occult thyroid carcinoma that was initially thought to be a lymph node metastasis, but proved difficult to diagnose. Preoperative contrast-enhanced computed tomography (CT) revealed partial thickening of the cyst wall, which led us to exclude not only ordinary lateral cervical cysts, but also lymph node metastasis from a malignant tumor and lymph node cyst. Therefore, we decided to submit the thickened part of the cyst wall for intraoperative rapid histopathology, and confirm the presence of malignant findings intraoperatively. Intraoperative rapid histopathology failed to reveal any evidence of malignancy, but the final histopathological diagnosis of the resected specimen was papillary thyroid carcinoma. The final pathological diagnosis of the excised specimen was papillary carcinoma of the thyroid gland. Even in consultation with the pathologist, it was difficult to diagnose thyroid cancer based on frozen-section histopathology alone, without prior information that the cancer originated from the thyroid gland. The results of the examination were explained to the patient and the usefulness of additional treatment, such as total thyroidectomy or right lobectomy, was explained to him; however, he refused to undergo such treatment and is being followed up as an outpatient. Although rare, the possibility of ectopic thyroid carcinoma or lymph node metastasis from an occult thyroid carcinoma should be borne in mind in the differential diagnosis of masses resembling lateral cervical cysts, and careful attention should be paid during the preoperative examination.

Thyroarytenoid muscle paralysis (TAMP), one of partial vocal fold paralysis, is often considered in the differential diagnosis of breathy hoarseness. Laryngeal electromyography (LEMG) is necessary for definitive diagnosis of this disease, however, this is a difficult and invasive procedure. Therefore, regular flexible fiberoptic endoscopy and laryngeal stroboscopy are often used clinically for the diagnosis of TAMP.

The vibratory characteristics on high-speed digital imaging (HSDI) were evaluated in 4 patients diagnosed as having unilateral TAMP by LEMG. Three cases were male and one was female, and all patients developed TAMP after surgery.

In all the 4 patients with TAMP, amplitude/phase asymmetry of vibrations between the bilateral vocal folds were observed on HSDI. Furthermore, in three patients, phase asymmetry was observed between the anterior and posterior portion (posterior-to-anterior opening type) of the diseased glottis, due to decrease of the TA muscle tension. This unique finding, that is, phase asymmetry between the anterior and posterior portion of the diseased glottis, may be a characteristic finding of TAMP on HSDI.

Deep neck abscess refers to formation of an abscess due to inflammation of the facial spaces in the head and neck area. Deep neck infection could be complicated by descending necrotizing mediastinitis when the inflammation spreads downward, but extension of the inflammation to the back and waist area is rarely observed. We report a rare case of a deep neck abscess in which the inflammation extended to the waist area. A 48-year-old man visited a neighborhood doctor complaining of neck swelling and fever. He was referred to our department with the suspected diagnosis of acute parotitis. We hospitalized the patient with a diagnosis of deep neck abscess, and performed emergent neck incisional drainage and tracheotomy. However, his inflammatory marker levels remained high, and a contrast-enhanced CT performed 6 days after the surgery showed that the abscesses now extended from the deep neck spaces and trapezius muscle to the parasternal region, erector spinae muscle, and lower right quadrant of the abdomen. We performed additional incisional drainage and thoracoscopic drainage jointly with thoracic surgeons, while continuing the antibiotic treatment. The abscesses gradually reduced in size after the last operation, and the patient was discharged home after 50 days of hospitalization. It is uncommon for a deep neck abscess to progress beyond the mediastinum to the waist area. However, if the general condition of a patient with a deep neck abscess does not improve with drainage by the cervical approach alone, it is necessary to conduct imaging examinations as soon as possible and perform appropriate incisional drainage with the cooperation of other departments.

Deep neck abscess is a severe infection encountered in otolaryngology practice, that can be associated with serious complications, such as descending mediastinitis, internal carotid thrombosis, and necrotizing fasciitis; development of pseudoaneurysms has also been reported as a rare complication. Herein, we report successful treatment of a patient with a pseudoaneurysm of the internal carotid artery that developed from an abscess in the carotid artery space, with a review of the literature.

The patient was an 80-year-old man who presented with the chief complaint of swelling in the lower left ear region and fever. Enhanced CT showed an abscess in the carotid artery space. Emergent incision and drainage of the deep neck abscess was performed under general anesthesia. The patient developed cerebral infarction after the operation, and cervical magnetic resonance angiography (MRA) confirmed the presence of a pseudoaneurysm in the left internal carotid artery. We followed up the patient conservatively with blood pressure control, but the aneurysm ruptured. The bleeding was successfully controlled and the patient’s life saved by successful endovascular coil embolization performed by a neurosurgeon.

Endovascular treatment is considered as one of the treatments for a pseudoaneurysm complicating a deep neck abscess.