Inverted papilloma (IP) in the paranasal sinus is a benign neoplasm with unique clinical characteristics; in particular, a high recurrence rate and concomitant malignant lesions. Because the clinical features of IP sometimes resemble unilateral paranasal sinusitis with polyps, the pre-operative diagnosis of IP is important for complete surgical resection. In this article, we postulate that measurement of serum squamous cell carcinoma antigen (SCCA) and detection of human papillomavirus (HPV) are very important for the diagnosis and treatment of IP.
SCCA, consisting of SCCA1 and SCCA2, was originally isolated biochemically from uterine squamous cell carcinoma (SCC) tissue and is one of the tumor markers for head and neck SCC. A statistically significant elevation of serum SCCA was observed in IP, compared to those with maxillary SCC and inflammatory nasal disease. Moreover, serum SCCA measurement is an effective tool to diagnose not only untreated IP but also recurrent IP. If a high SCCA level remains after surgery, surgeons should pay attention to the possibility of residual or subsequent recurrent lesions. The mRNA expression of SCCA1 and SCCA2 in IP was higher than in maxillary SCC and inflammatory disease. The SCCA2/SCCA1 ratio in IP was similar to that in inflammatory disease, although the ratio in maxillary SCC was significantly higher than in IP and inflammatory disease. Thus, the SCCA2/SCCA1 ratio is useful for detecting SCC among other sinonasal diseases.
There have been several reports regarding the close relationship between IP and human papillomavirus (HPV) infection. Using an auto-nested polymerase chain reaction, the presence of the HPV genome was detected in 46.2%, 27.3% and 7.7% of patients in IP, SCC, and inflammatory diseases, respectively. IP showed significantly higher HPV-positive rates than the inflammatory disease. All types of HPV detected were high-risk HPV, especially HPV-16. One patient with IP and concomitant squamous cell carcinoma showed a high viral load and integration. HPV infection may be involved in the pathogenesis of IP, and a high viral load and integration of HPV have an important role in malignant lesion in association with IP. Further study is needed to clarify whether HPV plays an important role in recurrence or dissemination of IP.
Since many surgical procedures and instruments have been newly developed for endoscopic sinus surgery, endoscopic resection of IP is becoming popular as the optimal treatment for IP. Further development in this field brings both less invasive treatment and lower recurrence rates to patients with sinonasal tumors.

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Patulous Eustachian tubes (PETs) have been thought to be relatively rare, but the morbidity rate seems to be increasing due to the growing interest in this disease. The symptoms of PET improve when the patients lower their head. The reason is speculated to be due to tightening of the Eustachian tube because of an increase in blood flow around the tube. In terms of this mechanism, we hypothesized that adenosin-5′-triphospahte (ATP) administration might have some effect in improving PET symptoms, because it could enhance blood flow of the tissue around the Eustachian tube. The study design was retrospective. The subjects comprised patients seen in our department from April 2004 to April 2009 and who were diagnosed as having PET. The diagnosis was made based on their symptoms and objective examinations of the Eustachian tube functions tests including sonotubometry and tubotympanoaerodynamography (TTAG). A total of 139 ears with PET from 104 patients were involved in the present study. All patients were given 300 mg/day ATP orally for an average of 3.1 months. To evaluate the effect, changes in the symptoms and the results of Eustachian tube function tests were compared between before and after the treatment. Symptoms were classified into 4 groups, complete remission, partial remission, no change and worse. Complete or partial remission was achieved in 106 ears (76.3% of the total). Durations in sonotubometry showed statistically significant improvement from an average of 316.9±204.9 daPa to 410.9±226.0 daPa (p<0.01, paired t-test). These results suggest that ATP was useful for the treatment of PET.

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The glomus tympanicum is a vascular-rich tumor arising in the tympanic cavity. There is still an argument regarding treatment, especially the necessity of preoperative embolization. We report on two cases of glomus tympanicum which were surgically treated via two different approaches without preoperative embolization.
Case 1: A 28-year-old female had pain of the right temporal region with ipsilateral hearing loss lasting over 4 months. Her right eardrum was seen bulging and was pulsatile. High resolution CT and MRI with gadolinium confirmed a vascular-rich tumor localized in the meso-and hypotympanum. These findings lead us to a diagnosis of glomus tympanicum. Tentative removal of the posterior canal wall in addition to the facial recess approach enabled us to achieve total removal of the tumor with a small amount of blood loss (44 ml).
Case 2: A 69-year-old female had a right pulsatile tinnitus and hearing loss over 8 years. Her right eardrum was remarkably hyperemic and presented with pulsation. CT and MRI, even without the use of gadolinium due to bronchial asthma, demonstrated an intratympanic tumor and mastoid granulation. The transcanal approach was selected with the aim of mastoid cells preservation for middle ear ventilation. Posteroinferior drilling of the tympanic annulus, chorda tympani transection, tentative removal of the incus, and malleus handle amputation provided us with better access to control the tumor, even though some difficulty was still encountered in working in the tympanic sinus and hypotympanum. The amount of blood loss was 70 ml.
In the present cases, different approaches were selected to remove the intratympanic glomus tumor with a similar extension. In both approaches, the intraoperative bleeding was relatively easily controlled, and these results may support the lack of necessity for preoperative embolization. From our experience, the facial recess approach combined with tentative removal of the posterior canal wall is considered safer to control glomus tumors extending into the tympanic sinus and hypotympanum.

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The postoperative results of type I tympanoplasty in short stay patients were analyzed in 330 ears.
Eighty-nine point six of the tympanic perforations were closed successfully. In the childhood group, the success rate was 76.9% which was statistically lower than the rate in the adult group.
The hearing results were successful in 91.1%. Poor results occurred in ears with tympanic reperforation, limitation of ossicular mobility and elevation of the bone conduction threshold.

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We report on the case of a patient with relapsing polychondritis (RP) without erythema and swelling of the external ears at the time of diagnosis. A 75-year-old woman complained about swelling and redness of the left external ear at the first visit and was followed during 26 months. For the diagnosis of RP, all patients must satisfy at least 3 diagnostic criteria of McAdam et al. Further, the criteria of Damiani and Levine require that patients must satisfy at least 1 diagnostic criteria of McAdam et al. with histological confirmation.
We had difficulty in making a definite diagnosis because our patient had only pain without swelling and redness at the second auricular chondritis. The patient’s condition improved after oral administration or drip therapy with prednisolone. Diagnosis was able to obtained from the patient’s condition on the basis of bilateral auricular chondritis, nasal chondritis, and the response to prednisolone. In one of the previous studies, Jung (1996) reported that the condition could be diagnosed by performing a biopsy even during an attack-free interval. Biopsy findings before the administration of prednisolone may facilitate a definite diagnosis at an early stage.
RP is associated with progressive inflammation and destruction of systemic cartilage and connective tissue. Although no specific laboratory tests are available for the diagnosis of RP, determination of type II collagen antigen and human leukocyte antigen (HLA)-DR4 are associated with RP. However, these tests require personal information and cannot be covered by health insurance. However, if the patients do not meet all the diagnostic criteria, these laboratory tests and biopsy should be performed at an early stage to avoid development of a serious condition because of a relapse.

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Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetically transmitted disease characterized by a systemic disorder of the blood vessels. Epistaxis is usually the most common symptom. Nasal dermoplasty is regarded as the effective treatment for moderate to severe cases.
We report on a 71-year-old man with HHT and a large septal perforation who was treated with nasal dermoplasty. Postoperatively, he has shown reduction in the frequency and severity of his epistaxis.

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We report a case of a nine-year-old boy with facial orbital subperiosteal abscess (SPA) arising from antecedent lacrimal sac infection. The patient presented at our hospital with high fever, swelling from right eyelid to cheek, and proptosis. A previous hospital had performed antibiotic therapy as initial treatment for a few days, and it was unsuccessful. The patient was initially diagnosed with severe infection of the orbit and face as a complication of sinusitis, because of his physical status and SPA and sinusitis documented on CT scan. On the same day, he underwent emergency surgical drainage by external incision. Pus was evacuated, and the abscess was recognized as not directly related with sinusitis, but induced from lacrimal sac infection. Streptococcus constellatus and Prevotella intermedia were isolated from the drained pus. He healed without serious sequela such as visual disorder. We conclude that early surgical intervention is required in cases with orbital SPA or orbital abscess that were unresponsive to antibiotic therapy or that manifest signs of serious complications such as proptosis, decline of visual acuity, disturbance of consciousness, and so on.

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Radiation therapy in patients with head and neck cancers often triggers severe painful mucositis.
Intensity Modulated Radiation Therapy (IMRT) allows higher radiation doses to be focused on regions within the tumor while minimizing the dose to surrounding normal critical structures. Recently IMRT has been used for the purpose of reduction of side effects. To better understand how IMRT is associated with fewer episodes of painful mucositis than conventional RT, we investigated examples of painful mucositis from 27 patients (IMRT group; 13 patients, conventional RT group; 14 patients) undergoing radiation therapy at 60-66 Gy for newly diagnosed mesopharyngeal cancer. We evaluated painful mucositis using numerical rating scale (NRS0-5) pain scores and Common Terminology Criteria for Adverse Events version 3.0 (CTCAE v3.0). We also investigated analgesic usage and the rate of receiving naso-gastric tube feeding.
The area of mucositis was smaller and the pain course was milder in the IMRT group compared with the conventional RT group.

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Pyriform sinus fistula is a cause of repeated suppurative thyroiditis or neck abcesses. Between April 2006 and March 2011, we encountered four cases of pyriform sinus fistula. The fistula was removed via two approaches, namely, direct hypopharyngoscopy via an external incision. To visualize the fistula, a dye solution was injected during hypopharyngoscopy. The fistula was identified by its staining in two cases. In one of the two cases, a partial thyroidectomy was performed. In contrast, we were unable to detect the fistula in two cases, because no staining could be observed. In one of the nonidentified cases, a partial thyroidectomy was performed and a semithyroidectomy in combination with a fistulectomy was performed in the other. No recurrence was observed except in a pediatric case during the follow-up period. To prevent recurrence, complete identification and extirpation of the fistula are mandatory. The fistula should be identified by a procedure appropriate for each particular case. We concluded that thyroid lobectomy is necessary for preventing recurrence if the fistula cannot be identified by staining during surgery.

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A 22-year-old woman presented at our hospital with foreign body sensation of the pharynx. Fiberscopy revealed a mass with dilated surface veins at the base of the tongue. Magnetic resonance imaging (MRI) showed a mass in the tongue base, and there was no thyroid gland in the anatomically conventional, para-tracheal position. Tc-scintigraphy showed vivid uptake at the same lesion as identified on MRI, and the normal anatomical thyroid position did not show any radioactive uptake. Thyroid function tests, free T4 and TSH, were normal. These findings supported an ectopic lingual thyroid. CT angiography showed bilateral lingual arteries which fed the lingual thyroid. We chose a lateral pharyngotomy approach for resection of the lingual thyroid to achieve a wide operative field. After ligating the lingual artery which feeds the ectopic thyroid, the mass was resected with minimal bleeding. Post-operative histopathological analysis confirmed that the specimen was normal thyroid tissue.

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Synovial sarcoma is a relatively rare malignant tumor of the soft tissue. The most common site of occurrence is the extremities, and they rarely occur in the head and neck region. Here, we report on a rare case of synovial sarcoma arising in the parapharyngeal space and parotid region. A 21-year-old man presented with left-sided painless subauricular swelling. Computed tomography (CT) revealed a dumbbell-shaped cystic mass in his left parapharyngeal space and parotid region. Under a tentative diagnosis of cystic lymphangioma, he received percutaneous local injection of OK-432, and the lesion showed drastic reduction temporarily. Seven months after the injection, the subauricular swelling recurred. He then received additional injections of OK-432 on 3 occasion, however, the mass did not decrease but rather increased. CT at this point showed a well-enhanced solid tumor measuring 80 mm in its major axis sitting in the parapharyngeal space and parotid region. The patient eventually underwent transcervical resection of the tumor. Microscopically, the tumor showed spindle cell and glandular epithelial structures and was positively immunoreactive for AE1/AE3, CAM5.2, EMA, bcl-2, calponin, and TLE-1, but not for S-100 and a-smooth muscle actin. In addition, the SYT-SSX1 fusion gene was detected with RT-PCR. From these findings, the tumor was diagnosed as a biphasic synovial sarcoma. The patient received postoperative adjuvant chemoradiotherapy (total 70 Gy+daily carboplatin) combined with thermotherapy. No evidence of recurrence has been seen for a 19-month follow-up period after surgery.

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We report here in on a case of malignant fibrous histiocytoma (MFH) of the left postauricular region. A 17-year-old male was referred to our hospital with swelling of the left neck. CT scan and MRI showed a 2 cm mass lesion in the deep neck, and PET showed abnormal accumulation in the cervical lymph nodes and distant organs.
Based on these findings, the tumor was considered as benign and was resected under general anesthesia. A histological examination showed that the tumor consisted of growing spindle cells with large irregular nuclei. Immunohistochemical staining with vimentin and α-SMA, showed that the tumor cells were positive. Finally the tumor was diagnosed as an MFH. Since the tumor was considered to be residual, we performed radical neck dissection as salvage surgery. To date, no local recurrence nor distant metastasis has been observed.

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We retrospectively analyzed the clinical characteristics of 41 consecutive patients with deep neck abscesses who were treated in our department between 1999 and 2011. The patients comprised 27 males and 14 females ranging in age from 4 to 88 years. Seven of them developed descending mediastinitis (mediastinum group), while the other 34 did not (neck group). The mediastinum group had a significantly longer hospitalization period (49.6±23.3 days vs. 20.9±11.2 days, p<0.001), higher serum CRP (26.3±10.9 mg/dl vs. 12.9±10.0 mg/dl, p=0.009), higher percent of patients who underwent tracheostomy (85.7% vs. 17.6%, p<0.001), and a higher detection rate of Streptococcus milleri group bacteria (71.4% vs. 23.5%, p=0.013) compared to the neck group. The percentage of patients with diabetes mellitus was on the higher side in the mediastinum group than in the neck group (42.9% vs. 14.7%, p=0.087). Diabetic patients were prone to develop mediastinitis (3/8 vs. 4/33, p=0.087), and showed a significantly longer hospitalization period (42.0±20.5 days vs. 21.8±15.0 days, p=0.004), higher white blood cell count (17160±5908/μl vs. 13045±6734/μl, p=0.041), and a higher percent of patients who underwent tracheostomy (62.5% vs. 21.2%, p=0.021) compared to nondiabetic patients. These results suggest that underlying diabetes mellitus and/or infection with S. milleri group bacteria are possible predisposing factors for the aggravation and prolongation of deep neck abscesses.

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A case of a rare nasopharyngeal foreign body is described. A 67-year-old female with sequela associated with a cerebral infarction presented with right nasal obstruction. Nasopharyngeal fiberoscopy from the left nasal cavity demonstrated that sea tangle had somehow been inserted into the right side of the nasopharynx. The foreign body was removed from the oral cavity under general anesthesia via oral intubation. The foreign body was confirmed as a piece of sea tangle measuring 7×3.2 cm.

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