The definitive diagnosis of vertebrobasilar insufficiency (VBI) at ear, nose and throat clinics is difficult. In addition, there is no established treatment policy for VBI at present. Therefore, VBI is generally diagnosed based on the "Diagnosis from Medical History" of "Materials for Standardization of Vertigo Diagnosis" prepared by the Japan Society For Equilibrium Research, with severity scoring (VBI score) additionally performed. In our previous study, treatment was administered orally to three groups: A (ATP + dilazep hydrochloride), B (ATP + ibudilast) and C (ATP + dilazep hydrochloride + ibudilast). Only in Group C the Dizziness Handicap Inventory (DHI) score show no significant improvement from the initial diagnosis to two weeks after starting treatment or from two weeks to four weeks after starting treatment. Furthermore, the VBI score, which focused on specific symptoms in VBI, improved significantly both from treatment initiation to two weeks later and from two weeks to four weeks later. Therefore, the regimen given to Group C was considered to be the most appropriate treatment for VBI. Building on the findings of that previous report, the subjects in this study were divided into two groups: D (ATP + ibudilast + tofisopam) and E (ATP + diphenidol). Autonomic nervous adjustment drugs have been reported to be effective for VBI, although we did not explore these agents in the previous report. Diphenidol reportedly exerts a spasm inhibitory effect by improving the blood flow and vascular smooth muscle activity of the vertebral artery, so we examined the effectiveness of diphenidol for VBI and compared the effects with Group C. In Group D, the VBI score was significantly improved from both the initial diagnosis to two weeks as well as four weeks later, the same result as seen in Group B. The DHI score was significantly better in Group D than in Group B from both the initial diagnosis to two weeks later as well as to four weeks later. In Group B, however, there was a significant difference in the DHI score only from the initial diagnosis to four weeks later. Taken together, these findings indicate a synergistic effect on the DHI score, but not on the VBI score, after adding tofisopam to the ATP + ibudilast regimen. In Group E, the VBI score improved significantly from both the initial diagnosis to two weeks as well as to four weeks later. However, no significant improvement was noted from two weeks to four weeks after starting treatment. The VBI score at four weeks after starting treatment was as good as that in Group C (ATP + dirazep hydrochloride + ibudilast). In contrast, regarding the DHI scorein Group E, the DHI score improved from the initial diagnosis to 4 weeks later by 15.7 ± 22.4 points, which was lower than the respective value of 25.0 ± 26.4 points in Group C. Taken together, these findings indicate that although diphenidol is effective for improving the symptoms specific to VBI, it was considered insufficient for improving the impairment of daily life caused by dizziness. Dirazep hydrochloride is effective for improving the symptoms specific to VBI , however, the drug cannot be administered in Japan since it is not covered as a treatment for VBI by the Japanese National insurance system. When anticoagulants have already been administered, ibudilast is difficult to use. In such a case, diphenidol is considered a relatively effective therapeutic agent for VBI.

We herein report a case of inner ear malformation similar to incomplete partition type Ⅲ (IP-3). A 7-year-old boy with mixed hearing loss had been wearing hearing aids since 9 months of age. His mother and younger twin sister also wore hearing aids. His parents consulted an otolaryngologist requesting cochlear implantation. Pure tone audiometry revealed that the patient had an air-conduction threshold of 100 dB bilaterally, but the bone-conduction threshold was 25-50 dB. The aided threshold was 35-45 dB. The patient was not indicated for surgery for cochlear implantation and was instead offered a thorough examination to seek out the underlying cause of his mixed hearing loss. However, the parents refused additional tests. The patient was then referred to the authors' department, again requesting cochlear implantation. Computed tomography and magnetic resonance imaging of the temporal bone reveraled that bony density of the otic capsule was low, modiolus was absent, and the cochleae were directly connected to the internal acoustic canals. This imaging feature indicated that the patient had an inner ear anomaly of IP-3. Patients with IP-3 who have residual serviceable hearing are recommended not to undergo cochlear implantation. Otolaryngologists who treat deaf children should be aware of the different mechanisms underlyng hearing loss due to different causes, and should be able to explain these mechanisms to patients' parents as simply as possible.

We experienced two cases of subacute to chronic invasive paranasal fungal infection with Aspergillus that occurred in patients who were elderly but who had no underlying disease that would otherwise impair their immune function and were difficult to diagnose and treat. Invasive fungal rhinosinusitis is fatal and has a poor prognosis if it progresses from the paranasal sinuses to the orbit, cavernous sinus, and cranium. However, the disease was brought under control by curetting the lesion as much as possible and administering antifungal drugs thereafter. The number of elderly people is expected to continue to increase in Japan, along with cases of invasive paranasal fungal disease that follow a chronic course. As chronic invasive fungal rhinosinusitis is an inflammatory disease of the paranasal sinuses, it is essential to accurately carry out its diagnosis and treatment.

Most iatrogenic foreign bodies in the maxillary sinus are caused by dental treatment. We experienced two cases of maxillary sinusitis caused by an iatrogenic foreign body which consisted of dental equipment, which is called a gutter percha point. In both cases, endoscopic modified medial maxillectomy was performed to remove the object and control infection, and the gutter percha point was found to be located in the maxillary sinus floor. We were able to preserve the involved teeth and obtained a good prognosis without any symptom recurrence following an operation. Various approaches may be adopted for removing a foreign body located in the maxillary sinus. It is necessary to consider minimally invasive treatment, and moreover we should consider the postoperative prognosis and the patient's desire for tooth preservation in such cases. Of note, if any bits of the foreign body remain after surgery, there is a high possibility of dissatisfaction with medical treatment. We can reliably approach the maxillary sinus floor by endoscopic modified medial maxillectomy. We consider endoscopic modified medial maxillectomy an excellent approach for managing iatrogenic foreign body due to root canal filling located in the maxillary sinus.