The principle behind transcanal endoscopic ear surgery (TEES) is to take full advantage of the ear canal as the most logical, direct and natural access point to the tympanic cavity and beyond. However, TEES and its potential could not be fully unlocked until the emergence of high definition (HD) imaging technology. An HD system provides a sparkling clear image with high contrast, which virtually eliminates the disadvantages of its 2D image. We have now achieved high resolution well beyond the resolution of the retina. In addition, some additional improvement can be achieved through the visual enhancement tools system which shifts the color spectrum. These advances in endoscopy have allowed a smaller endoscope to be incorporated into TEES.

The main obstacle which must be overcome in TEES is how to simultaneously use the endoscope along with other surgical instruments. While the external auditory canal (EAC) has proven to be wide enough to insert an endoscope, we also have to insert other instruments side-by-side in this narrow space. The narrowness of the EAC not only severely limits the manipulation of an instrument, it also does not permit insertion of a second instrument. While advances have been achieved in robotic surgery, again the narrow confines of the ear have prevented the use of such techniques in ear surgery. However, rather than simply wait for the miniaturization of the tools used in robotic surgery, we need to develop new surgical procedures to advance our field of ear surgery.

In this article, I will discuss how to deal with middle ear disease using TEES. Moreover, I shall show that TEES is safe and efficacious using rigid endoscopes with an outer diameter of 2.7 mm and is less invasive for patients by using the EAC as an access route to the middle ear.

We encountered a very rare case of subcutaneous emphysema in the external auditory canal in a patient presenting with conductive hearing loss. The patient was a 11-year-old boy who had noticed narrowing of his left external auditory canal without pain since 7 months ago. About a month prior to his visit, he had also become aware of hearing loss in his left ear without apparent cause. Examination at a local clinic revealed swelling of the posterosuperior portion of the left external auditory canal and left conductive hearing loss, and the patient was referred to our hospital. On examination, the tympanic membrane on the left side was difficult to visualize because of stenosis of the external auditory canal. Pure-tone audiometry revealed conductive hearing loss of 55 dB in the speech frequency area in the left ear. CT imaging showed that the left external auditory canal was filled with an air bubble and had some bone defects in the posterosuperior portion. We diagnosed subcutaneous emphysema of the external auditory canal, cut the skin over the swollen area of the canal and then packed the canal with gauze impregnated with antibiotics for 1 week. The swelling of the left external auditory canal gradually decreased, resolving entirely by 4 months, with the hearing in the left ear also returning to the normal range. We speculated that the subcutaneous emphysema in the external auditory canal was caused by the rising middle ear pressure resulting from tubal dysfunction and the bone defects in the posterosuperior portion of the external auditory canal.

Invasive fungal paranasal sinus mycosis, often manifesting with the symptoms of severe headache and visual impairment, sometimes results in death. Therefore, early diagnosis and prompt treatment are necessary. We encountered four cases of invasive fungal paranasal sinus mycosis, in all of whom the condition was successfully cured by administration of voriconazole after endonasal endoscopic surgery. Three patients complained of visual impairment at the first clinical examination, and 1 of these patients showed full recovery. Caution should be exercised against the development of liver dysfunction during treatment with voriconazole, and towards this end, continuous monitoring of the serum concentrations of voriconazole is necessary.

Because accessory parotid gland tumors are relatively rare, no standard management method has been established yet. In this paper, we describe the surgical approach and usefulness of facial nerve monitoring in a patient with pleomorphic adenoma of the accessory parotid gland. The patient, a 61-year-old female, presented with a painless, hard mass on the left cheek. We performed surgical resection of the tumor by the peri-auricular-cervical flap approach. The buccal branch of the facial nerve was easily detected on the tumor by nerve integrity monitoring (NIM). No postoperative facial nerve palsy was observed. Histopathology of the resected tomor, which measured 23×17×18 mm in size, revealed that it was a pleomorphic adenoma. NIM was useful in the for safe resection of the accessory parotid gland tumor.

No effective treatment has been established yet for incurable and radioactive iodine-refractory differentiated thyroid carcinoma (RAI-refractory DTC). With the recent progress in the field of molecular biology, some gene mutations leading to thyroid carcinomas have been identified, and molecular-targeted drugs targeting these gene mutations have been developed for clinical application. Sorafenib has been demonstrated in a phase III trial to significantly prolong the progression-free survival in patients with RAI-refractory DTC. At our center, we have started to use sorafenib for RAI-refractory DTC, and herein, we report the course of treatment in these cases.

In all, 4 patients with RAI-refractory DTC have been treated with sorafenib at our department. The duration of sorafenib treatment ranged from 10 to 410 days. The side effects observed included hand-foot syndrome in 4 patients and alopecia in 3 patients. Diarrhea, hypertension, and liver dysfunction were observed in one patient. Serious liver dysfunction was observed in one patient. All patients required sorafenib dose reduction, and suspension of sorafenib administration was necessitated in two patients. Sorafenib treatment needed to be discontinued altogether in one patient because of the development of hand-foot syndrome.

We performed imaging examination at 6 months after the start of treatment, and evaluated the therapeutic effect according to RECIST. In the patient who received only short-term administration (10 days) due to the development of hand-foot syndrome, the tumor size had slightly increased (18% increase). However, in the patients who had received the treatment for several months, the therapeutic response was relatively good (0 to 25% decrease in tumor size). Hand-foot syndrome is the most commonly encountered adverse effect of sorafenib, that frequently necessitates treatment discontinuation. However, in most cases, the syndrome can be controlled by taking appropriate measures. To achieve a sufficient therapeutic effect, it is important to continue administration of sorafenib while taking measures to control hand-foot syndrome.

Hypopharyngeal spindle cell carcinoma (SpCC) is rare. It is a biphasic tumor consisting of a combination of sarcomatous features and squamous cell carcinoma. We present the case of a 65-year-old man with a large hypopharingeal SpCC. The patient presented with the chief complaints of dyspnea and swallowing disorder. Biopsy specimens obtained from the bulky mass extending from the hypomesopharynx to the thoracic esophagus revealed suspected carcinosarcoma. Total pharyngolaryngoesophagectomy with bilateral neck dissection was performed. Since histopathology revealed the diagnosis of SpCC with left cervical lymph node metastasis, the patient received postoperative chemoradiotherapy. No recurrence has been seen in the 21 months since the initial treatment.

Angiosarcoma is a rare disease that accounts for about 1%–2% of all soft-tissue sarcomas and is a highly malignant tumor with a poor prognosis. Albeit not very common, in some cases, angiosarcomas can be induced by irradiation. In this study, we report the case of a patient who developed angiosarcoma at the site of previous postoperative radiotherapy for tongue cancer. The patient was a 63-year-old woman who had undergone surgery for tongue cancer (T4aN2cM0) and received irradiation (50 Gy in total) to the cervical region. The postoperative course had been uneventful, without recurrence. However, 10 years after the surgery, she began to develop a dark-red tumor in the right lower jaw, which was diagnosed as angiosarcoma by biopsy. Because imaging revealed evidence of neither lymph node metastasis nor distant metastasis, tumorectomy with reconstructive surgery using a pectoralis major myocutaneous flap was performed. She then received postoperative adjuvant chemotherapy. Thereafter, she has had an uneventful course, without any evidence of recurrence until date. This case serves to underscore the fact that exposure to radiation can result in new malignant tumor formation. Therefore, such patients need to be explained about the possibility of development of radiation-induced tumor and about the need for long-term follow-up after radiotherapy; they should also receive instructions to visit a medical facility in case they notice any abnormality at the site of previous irradiation. In the event a patient develops any abnormality, such as redness and/or swelling, at the site of previous irradiation, he/she a patient should immediately be worked up under the assumption of not only recurrence of the primary disease, but also possible radiation-induced tumor. The diagnosis must be established by methods such as biopsy.

Salivary duct carcinoma (SDC) is a rare malignant tumor with a poor prognosis. Usually, operation and radiation are carried out as the standard treatments. However, no chemotherapy regimen has been established because of the rarity of this carcinoma. SDC histologically resembles invasive breast ductal carcinoma. Recently, overexpression of human epidermal growth factor receptor-2 (HER-2) has been reported in SDC also, besides breast cancer. We report a case of metastatic SDC who received long-term treatment with trastuzumab.

The patient was a 62-year-old male who presented with a left neck swelling and a feeling of sensory discomfort along the left submandibular bone. He underwent sialoadenectomy with bilateral neck dissection and postoperative radiation, followed by chemotherapy (cisplatin and docetaxel). Immunohistochemistry showed overexpression of the HER-2 protein in the tumor cells. No local recurrence has been detected, however, the patient presented with lung metastatic lesions that were increasing in size. Therefore, we started him on trastuzumab. At present, the metastatic lesions are still progressing, albeit slowly, and the patient has been taking trastuzumab for 42 months without side effects. The patient survives until date, 59 months after the initiation of therapy. A trastuzumab-based regimen is a potentially valid therapeutic option for advanced SDC.

Contrast-enhanced computed tomography (CT) is useful for the detection of a head-and-neck abscess. However, adverse reactions to contrast agents medium can rarely occur. Therefore, we compared the detection rate of head-and-neck abscesses between plain CT and contrast-enhanced CT. Our study population included 10 patients with infection of the head-and-neck region. Seven patients were diagnosed as having an abscess. Ten otorhinolaryngologists interpreted the findings on plain and contrast-enhanced CT to determine the presence of an abscess in the 10 study participants. The detection sensitivities of plain CT and contrast-enhanced CT for a head-and-neck abscess were 91.4% and 98.6%, respectively. Plain CT, without injection of a contrast medium, is useful for the diagnosis of head-and-neck abscess. The limitations of this study were that our study population was small, and we selected typical cases.

Fractional exhaled nitric oxide (FeNO) concentration is regarded as a useful biomarker of the grade of eosinophilic inflammation in the lower respiratory tract. This study was aimed at investigating the usefulness of FeNO measurements in patients with eosinophilic chronic rhinosinusitis (ECRS). FeNO concentrations were measured in 45 patients with ECRS under the following two different conditions. In 35 patients, the measurements were conducted at the initial presentation or prior to surgery, while in the remaining 14 patients, they were conducted when the patients developed aggravation of their sinusitis and/or an altered sense of smell. The former 35 patients comprised 21 patients diagnosed previously as having bronchial asthma (BA) and 14 with no diagnostic history of BA at the initial presentation. Four of these 14 with no history of BA had high FeNO concentrations and were newly diagnosed as having BA; therefore, there were 25 patients with BA and 10 without BA in whom the measurements were conducted preoperatively. The average FeNO concentration was significantly higher in the BA group (71.4±28.9 ppb) than in the non-BA group (26.7±11.5 ppb). The average FeNO concentration in the 14 post-operative patients was 107.2±41.4 ppb. Their inhalation therapy was intensified, and a month later, the average FeNO concentration significantly decreased to 62.6±44.9 ppb. The size of the nasal polyps decreased in 71% of the patients, the subjective sense of smell improved in 58%, and lower respiratory symptoms improved in 82%. Systemic steroid administration was only needed in 4 patients. We suggest that monitoring of FeNO during ECRS therapy is useful for the following reasons: to detect undiagnosed BA, possible efficacy of intensification of lower respiratory inhalation therapy on ECRS assessed using FeNO as an index, and to assess the possibility of reducing the systemic steroid dose after intensification of inhalation therapy.