Eosinophilic chronic rhinosinusitis (ECRS) is a known subtype of chronic rhinosinusitis, characterized by the presence of nasal polyps with eosinophilic infiltration. It is a refractory disease that often fails to resolve even with endoscopic sinus surgery (ESS), and is closely associated with late-onset-bronchial asthma. Thus, this disease is clinically important, and often concurrent treatment for both ECRS and asthma is necessary. We call such total airway treatment, “Airway Medicine.” The comorbid inflammation is another aspect of the “one airway, one disease” concept. We recently reported on the efficacy of inhaled corticosteroids (ICS) for ECRS patients with late-onset-bronchial asthma. On the other hand, ECRS is characterized by easy recurrence of nasal polyps, even after ESS. The endpoints of ESS are different from those for other types of CRS. Full-House ESS is necessary for ECRS, because of the more difficult drug delivery associated with reduction of the mucosal surface area of the ethmoid sinus. Complete ESS and Airway Medicine can potentially decrease the recurrence rate of ECRS.

In Japan, patients with IgA nephropathy are often treated by a combination of tonsillectomy plus steroid pulse therapy. Basic research in recent years has provided sufficient evidence to show that IgA antibodies and T cells derived from the tonsillar palate reach the glomeruli through the systemic circulation, lending further support to the validity of tonsillectomy as a means of therapy for this disease. There are many published reports about the postoperative course of renal function in these patients, but very few on the course of these patients during the perioperative period. In this study, we investigated the clinical characteristics of IgA nephropathy patients who had been treated by tonsillectomy plus steroid pulse therapy during the perioperative period, including the postoperative hemorrhage rate, and postoperative pain. We provide the descriptive statistics of 94 patients who underwent tonsillectomy plus steroid pulse therapy between April 2009 and March 2018. The average age of the patients was 34.7, with the patients ranging in age from 5 to 70 years; 57% were men, and the annual number of operations performed increased steadily from 2009 to 2018. The median disease duration was 24 months (range, 2 to 480 months). While tonsillectomies were performed in low-risk, intermediate- and high-risk groups, the surgery was not performed in the very high-risk group. In 65% of cases, the tonsillectomy was performed before the steroid pulse therapy. The postoperative hemorrhage rate was 5.3%, although the bleeding was not severe in any of the cases. The timing of the bleeding was distributed between immediately after the operation to about one week after the operation. Oral intake was used as an indicator of pain, and 98% of cases were able to resume oral intake within 3 days after the surgery. Tonsillectomy plus steroid pulse therapy has been undertaken in IgA nephropathy patients of widely varying ages, and the number of these patients receiving this treatment is expected to increase further in the future. The treatment is considered to poorly effective for for highly advanced cases, but no consensus has yet been reached on the patient selection criteria. In the future, we plan to accumulate more cases of IgA nephropathy and to examine the long-term renal prognosis of patients treated by tonsillectomy plus steroid pulse therapy.

We retrospectively studied the clinical characteristics of 11 patients with pyriform sinus fistulas of the hypopharynx. The 11 patients consisted of 6 males and 5 females, aged 2–79 years, with a median of 41 years. The left side was affected in 10 cases. Six patients had a past history of acute suppurative thyroiditis. Eight patients had a severe neck abscess and had undergone incision and drainage. Fistulectomy was performed in 7 patients, with concomitant partial/hemithyroidectomy in 5 of these patients. Four patients developed recurrence after fistulectomy, whereas no recurrence was seen in any of the patients in whom no fistula was identified. The recurrence rate was 75% (3/4) in the patients who had undergone incision and drainage of the abscess, and 33% (1/3) in those who had not. In addition, the recurrence rate was 33% (1/3) in the patients in whom a fistula had been identified during the operation, and 75% (3/4) in whom a fistula had not been identified intraoperatively. The median age of the patients who developed recurrence was 23.5 years (range, 2–46 years), while that of the patients who did not develop recurrence was 56 years (range, 5–79 years).

These results suggest that fistulectomy following incision and drainage of the neck abscess, fistulectomy without identification of a fistula, and young age are possible risk factors for recurrence of pyriform sinus fistula of the hypopharynx.

Pyogenic granuloma is a benign tumor of the dermis and mucosa. Pyogenic granuloma in the head and neck region most frequently arises from the oral and nasal cavity, and rarely from the hypopharynx.

Herein, I report a case of pyogenic granuloma in the hypopharynx. A 72-year-old man presented to us with pharyngeal discomfort. Laryngoscopy revealed a mass with an adherent white exudate in the hypopharynx. Tracheostomy was performed under local anesthesia. Biopsy of the mass revealed necrotic tissue and granulation tissue with inflammation. The mass was removed by laryngomicrosurgery under general anesthesia with a carbon dioxide laser for diagnosis. Histopathological examination revealed the diagnosis of pyogenic granuloma. The postoperative course was uneventful, with the patient showing no signs of recurrence for 2 years after the operation.

I wish to emphasize the need to bear in mind the possibility of pyogenic granuloma in patients presenting with a mass with an adherent white exudate in the hypopharynx.

IgG4-related disease (IgG4-RD) is a multi-organ disease characterized by elevated serum IgG4 concentrations, tissue infiltration by IgG4-positive plasma cells, and hypertrophic lesions with fibrosis. Various organs can be involved, including the salivary glands, thyroid, pancreas, bile duct, retroperitoneum, etc.

A 71-year-old man who had received radiation therapy for laryngeal cancer presented to us with swallowing difficulty, dyspnea and anemia. Examination revealed an ulcer in the pharyngeal mucosa, and a biopsy was performed. Based on the histopathological findings, the ulcerative lesions were diagnosed as IgG4-RD. The swallowing difficulty, dyspnea and anemia improved soon after the patient was initiated on prednisolone treatment. A high index of suspicion for IgG4-RD must be held in patients presenting with edematous lesions of the pharynx that are difficult to diagnose.

Non-occlusive mesenteric ischemia (NOMI) refers to irreversible intestinal ischemia and necrosis in the absence of organic obstruction in the mesenteric blood vessels. In cases of delayed diagnosis, the prognosis is extremely poor. Herein, we report 2 cases of NOMI that developed while the patients were receiving chemotherapy for head and neck cancer. Case1: A 63-year-old female was recieving TPF (docetaxel, cisplatin, 5-FU) chemotherapy for maxillary cancer. One week after she received the drugs 1 cycle, the patient complained of abdominal pain and her blood pressure suddenly dropped. Blood tests showed elevated blood levels of biliary enzymes, decreased renal function, elevated inflammatory response marker levels, and leukopenia. Abdominal CT showed no obvious obstruction of the intestine. We suspected NOMI, and an emergency operation was performed. Exploratory laparotomy revealed that the colon was extensively necrotic. Colectomy and colostomy were performed. Case2: A 71-year-old male was receving TPF chemotherapy for laryngeal cancer. Five days after he recieved the drugs, the patient developed abdominal pain and vomiting. Blood tests showed elevated levels of hepatobiliary enzymes and amylase, decreased renal function, and leukopenia. Abdominal contrast CT showed no obstruction of the intestine. We made the diagnosis of NOMI, and performed emergency surgery. Intraabdominal exploration revealed that the colon was partially necrotic, and the necrotic segment was excised. The postoperative clinical course was uneventful, and the patient subsequently underwent pharyngo-laryngo-esophagectomy for laryngeal cancer. In both cases, myelosuppression and enteritis were observed during the chemotherapy, prior to the onset of NOMI. Considering the patients’ clinical courses, an association was suspected between the onset of NOMI and the chemotherapy. Docetaxel and 5-FU are known to have the ability to damage the intestinal mucosa. It is thought that NOMI developed in these patients because of the increased intestinal pressure due to constipation in the presence of intestinal mucosal damage and enteritis. Thus, it should be borne in mind that chemotherapy with docetaxel and 5-FU for head and neck cancer can sometimes cause serious complications, including NOMI. Clinicians should be aware of these complications and must also pay attention to systemic symptoms, besides symptoms related to the head and neck.

Necrotizing cervical soft tissue infections (NCSTIs) are destructive and rapidly progressive infections causing extensive necrosis of the fascia, subcutaneous tissue, skin, and muscle. They are often life-threatening; therefore, prompt diagnosis and appropriate treatment, such as early surgical intervention and antibiotic therapy, are crucial. Herein, we report four cases of NCSTI. All of the patients presented to our hospital with cervical edema and pharyngeal or cervical pain. One patient was diagnosed as having group A streptococcal infection and went into a shock state by 3 h after admission to our hospital. In two patients (50% of the cases), computed tomography at the first visit revealed the presence of gas in the soft tissues. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, which has been used as a surrogate marker for early diagnosis of NCSTI, was high in three (75%) cases when the cut-off score of ≥6 was used. The infection was successfully controlled in all the patients by aggressive treatment, including empiric antibiotic therapy, surgical debridement, and wound cleaning by daily wound irrigation, and all the patients survived without any complications. Although NCSTI in the head and neck is rare, it is sometimes indistinguishable from cellulitis, and otolaryngologists must be aware of this disease entity and should bear in mind the possibility of this condition in patients presenting with a condition resembling cervical cellulitis.

Kirschner’s wires are widely used for fixation of bone fractures, and their migration sometimes causes serious complications. A 46-year-old male who sustained a clavicular fracture in a traffic accident, underwent right clavicular osteosynthesis with a plate and Kirschner’s wire. Nine months after the surgery, at the time of its scheduled removal, the wire could not be located, and it was assumed that it had migrated into the neck. Therefore, the patient was referred to our ENT department. He had no symptoms at the time of admission, however, a neck CT revealed that the wire was located deep in the neck, near the brachiocephalic artery, brachiocephalic vein, and subclavian artery. Eight days after admission, it was removed via a neck skin incision under general anesthesia. We used video-fluoroscopy during the surgery to identify the precise location of the wire (28 mm in length, with a sharp edge) deep in the scalenus anterior muscle. Finally, the wire was removed successfully without any complications and the patient was discharged 5 days postoperatively. This case experience suggested that for safe removal of a foreign body with a sharp edge located deep in the neck, precise evaluation of the location by preoperative CT and even video-fluoroscopy, if necessary, during the surgery is quite important.

Stimulating the vestibular system for a certain period of time while changing the visual input using a reverse prism or lens is known to change the gain and phase of the vestibulo-ocular reflex (VOR); this phenomenon is known as VOR adaptation. The method for examining VOR adaptation involves addition of rotational stimuli and visual stimuli simultaneously in specific time units. Generally, black and white stripes are projected onto a circular screen when adding visual stimuli. When looking at the indicator moving on the circular screen, the subject perceives a circular vection (CV), as though it was turning in the opposite direction to the rotational direction of the visual stimulus. Conversely, the subject perceives a linear vection (LV) for a visual stimulus moving in a straight line, as though it was moving in the opposite direction to the linear of the visual stimulus. These results suggest that even if the indicator patterns are the same in the brain, rotational and linear movements may be processed as stimuli of different modalities. In this study, we added continuous rotational stimuli while projecting visual stimuli onto a flat screen, instead of the circular screen that is normally used for this test, to ascertain the effect of differences in the modality of movement of visual stimuli on VOR adaptation. We used two types of visual stimuli as the visual stimuli, namely, -1 stimulus, which is a visual stimulus in the same direction as the rotary chair, and the X2 stimulus, which is a stimulus in the opposite direction. There were no significant changes in gain for either pattern. Visual stimuli on a flat screen are perceived as linear stimuli, therefore, rotational stimuli are processed as inappropriate sensory information for VOR; thus, there is, no change in gain.