Numerical values are generally used to measure the values of things and to analyze differences in the values. The concept of a scoring system is thought to be useful to better recognize the conditions of patients with certain diseases and is widely used in the medical field. We propose four useful scoring systems for sinonasal diseases: the nasal symptoms questionnaire (NSQ), the self-administered odor questionnaire (SAOQ), the operating score (OP score), and the postoperative endoscopic appearance score (PEAS). The backgrounds and significances of these scoring systems are methodologically and clinically described. The NSQ, consisting of 10 symptoms- and quality of life (QOL)-related items, has been well-verified based on analyses of the predictive validity, test-retest reproducibility, internal consistency reliability, and sensitivity. The SAOQ, consisting of 20 odor-related items selected based on previous olfactory studies, was initially proposed for assessing olfactory function in 2003 by the Japanese Rhinologic Society, and its acceptability, validity, and sensitivity have been statistically validated. The OP score, used to assess the intra-operative severity of sinonasal conditions during endoscopic sinus surgery (ESS), can be a predictor of the postoperative clinical course in patients with chronic rhinosinusitis (CRS); analyses of the concurrent validity of the OP score indicate that CRS patients with more severe operative findings require longer post-operative management. The PEAS, which has been demonstrated to show high-level concurrent validity and inter-rater reliability, can be one of the useful endoscopic sinonasal evaluations in the postoperative period. When the clinical courses can be predicted before treatments using these scoring systems, appropriate treatments can be initiated at an early stage, and consequently, the efficacy of treatments can be improved, in patients with sinonasal diseases.

The major animal host of Streptococcus suis (S. suis) is the pig. S. suis can cause a zoonotic disease in humans that is characterized by meningitis, sepsis, arthritis, and endocarditis. It is a rare disease, with only about 26 cases reported from Japan; meningitis is observed in 70% of cases and hearing loss in 50% of cases.

The patient was a 60-year-old man, who initially presented with fever and sore throat. His symptoms were relieved with the medication prescribed by his family doctor. The following day, he came to our hospital complaining of dizziness and hearing loss on the left side. Hearing tests revealed left-sided deafness. He was admitted to our hospital for sudden hearing loss, but blood examination showed a prominent inflammatory reaction. He had complained of severe low back pain from the beginning, and gradually also developed headache and neck pain, which led to the suspicion of meningitis and confirmation, by a neurologist, of the diagnosis of bacterial meningitis by CSF examination. A few days later, S. suis was detected in blood and spinal fluid cultures.

We encountered a case of acute sensorineural hearing loss associated with S. suis meningitis, which is a recognized occupation-related disease, such as in employees of the pig industry. The patient was in the restaurant business, and the infection was suspected to have been transmitted through a cut wound while he was cooking raw pork. Because of the high incidence of infectious meningitis and concomitant hearing loss in patients with this disease, it is important for otolaryngologists to be aware of this disease.

Various treatments are used for patients with a patulous eustachian tube. Most reports of oral treatments in Japan refer to the use of Kampo medicines. We assessed the effects of Kampo treatment for a patulous eustachian tube.

Methods: We conducted a retrospective survey of 22 patients with a patulous eustachian tube who received treatment with Kampo medicines from August 2014 to June 2020. We prescribed Kampo medicine for 2 to 4 weeks initially, and then continued the medicine or changed the type of Kampo medicine, depending on the condition.

Results: The patients ranged in age from 26 to 85 years, with average of 64.0 years; there were 7 males and 15 females. In regard to the subjective symptoms, all 22 patients (100%) complained of autophonia, 21 patients (95%) complained of aural fullness, and 9 patients (41%) complained of hearing their own breath sounds. All the patients showed improvement of the symptoms with changes in the body position. Respiratory tympanic membrane sway was observed in 9 patients (41%). The Kampo medicine was effective in 19 patients (86%), and ineffective in 3 patients (14%). Of the cases in which it proved effective, 15 cases received kamikihito, 2 cases received byakkokaninjinto, and 1 case revieved goshajinkigan and kamishoyosan.

Conclusion: Treatment with a Kampo medicine was effective in 86% of cases with a patulous eustachian tube. In particular, kamikihito was effective in 68% of cases, and is considered as a first-line treatment agent. If this medicine proves ineffective, the response rate can be improved by selecting another Kampo medicine.

Malignant external otitis is a serious and potentially life-threatening condition, that occurs almost exclusively in the elderly, diabetic patients, and immunocompromised hosts. The infection begins in the external auditory canal and spreads progressively along the soft tissues and bone of the skull base, resulting in cranial nerve palsies and osteomyelitis.

We present our experience with seven patients diagnosed as having malignant external otitis. All patients complained of severe ear pain or headache that became worse at nights. Four patients developed cranial nerve palsies and three developed skull base osteomyelitis.

All the patients received long-term antibacterial or antifungal therapy. Five patients underwent surgical debridement and one was well controlled with hyperbaric oxygen therapy (HBO). Two of the seven patients died of malignant external otitis and none of the patients developed recurrence.

We consider that severe earache or headache that worsens at night is one of the most important clues to the diagnosis of malignant external otitis. Based on our review, we would recommend surgical debridement and HBO in addition to antibiotic therapy for treatment. Long-term follow up is necessary for preventing recurrence.

Nasal septal abscess has rarely been encountered in clinical practice in recent years. We report the case of a 75-year-old man who had a nasal septal abscess, probably caused by nasal tinkering. The patient presented with an approximately 1-year history of episodes of nasal bleeding. He had been prescribed an ointment for topical nasal application by a neighborhood doctor and had applied the ointment with his fingers. He then visited the local doctor with complaints of nose pain, low-grade fever, and nasal congestion. As the symptoms did not improve with the prescribed treatment, he was referred to our hospital. Medical examination at our department led to the suspicion of nasal septal abscess; therefore, an incision was made under local anesthesia, followed by administration of antibiotic and steroid therapy for 4 days. However, this treatment also failed, and local incision and drainage was repeated under local anesthesia in the operating room. The abscess resolved, and no recurrence has been observed for 6 months after the operation, and there are no sequelae, such as saddle nose. With the advances in the development of effective antibacterial drugs, nasal septal abscess has become a rarely encountered disease in recent years. However, the clinical course of cases with severe nasal septal abscess can be complicated by meningitis and sepsis. There is also the possibility of sequelae, such as saddle nose, after treatment. In patients presenting with symptoms such as nasal obstruction, nasal pain, and low-grade fever, it is important to have a high index of suspicion and make an early diagnosis of nasal septal abscess by proactive endoscopy. In this patient reported herein, the traumatic effect of frequent application of an ointment with unwashed fingers for about one year was considered to have caused a nasal septal abscess.

We report a case of acquired postnatal nasal cavity closure in a 61-year old woman. She visited our department with a 1-year history of bilateral submandibular and lacrimal gland swelling. She had undergone treatment for adult-onset Still’s disease 10 years ago, and also had suffered from chronic rheumatoid arthritis for 10 years. Erosion of the intraoral mucosa, adhesion of the mucosa of the right nasal cavity, and a completely closed left nasal cavity were observed at the first medical examination. The serum IgG was within normal range at 1,431 mg/dL; however, the serum IgG4 level was elevated to 224 mg/dL. For the purpose of diagnosis and improvement of rhinostenosis, endoscopic nasal surgery was performed under general anesthesia; the nasal septum was reconstructed, and the bilateral inferior nasal conchae were resected. The nasal septum was adherent to the right inferior nasal concha, and the left nasal cavity was completely closed. We performed lysis of the adhesions on the right side and removed the closed area on the left side; both sides of the nasal cavity were opened widely. Treatment with oral prednisolone (30 mg) was initiated at one month after the surgery, following a diagnosis of aggravation of IgG4-related Mikulicz disease. The condition in the nasal cavity improved, and no further disease progression was detected. As the prednisolone dose was gradually tapered, erosions were observed in the nasal cavity bilaterally, with subsequent narrowing of the left nasal cavity within acceptable limits. We speculate that the autoimmune disease contributed to closure of the nasal cavity.

Herein, we report a case of allergic bronchopulmonary aspergillosis (ABPA) that showed improvement at the follow-up visit of the patient after endoscopic sinus surgery (ESS) for fungal sinusitis. A 59-year-old woman initially visited the department of respiratory medicine for an abnormal opacity on the chest X-ray. She had a history of bronchial asthma and recurrent pneumonia. After careful clinical examinations, she was diagnosed as having ABPA, treated for asthma, and advised to return for regular follow-up examinations. One year later, she visited our department complaining of nasal discharge and nasal obstruction, and sinus computed tomography (CT) revealed a soft tissue density, mainly in the left maxillary sinus. Since the serum total immunoglobulin E (IgE) level and peripheral blood eosinophil count were elevated and the test for Aspergillus-specific IgE antibody was also positive, we suspected allergic fungal rhinosinusitis (AFRS) with concomitant ABPA. ESS was performed, with complete removal of the fungal debris from the sinuses. On histopathology, Aspergillus species were detected in the fungal debris, but no eosinophilic inflammation was found in the sinus mucosa, suggesting the diagnosis of noninvasive fungal sinusitis. Postoperative chest CT showed improvement of the abnormal opacity on the chest x-ray and reduction of both the serum total IgE level and peripheral blood eosinophil count. Further improvement was achieved with the use of itraconazole for one more year. Clinical observations in this case strongly suggest that removal of fungi from the sinuses by upper airway sinus surgery might result in improvement of the lower airway symptoms of ABPA.

Acute leukemia is a hematopoietic disease, associated with progressive bone marrow failure. Many acute leukemia patients are well known to experience oral-pharyngeal symptoms, presenting ENT doctors with the opportunity to examine them. Herein, we report the case of a patient who initially visited our ENT department complaining of sore throat and difficulty in swallowing and was eventually diagnosed as having acute leukemia.

The patient was a 24-year old man who presented to us with a 4-day history of throat pain. We confirmed pharyngeal pain and an inability to swallow. The patient had fever and swelling of the right peritonsillar region, but no throat congestion. We also detected laryngeal edema and ecchymoses in the upper pharynx. Based on his clinical condition and results of automated blood examination, we initially assumed typical upper respiratory tract inflammation. We treated the patient with antibiotics and steroids, which led to improvement of his condition. However, three days after his hospitalization, we rechecked his blood cell counts by manual techniques and diagnosed acute promyelocytic leukemia. We concluded that disseminated intravascular coagulation (DIC) had caused the ecchymotic patches in the upper pharynx, and that the unilateral peritonsillar swelling had been caused by an opportunistic bacterial infection associated with the decreased white blood cell count.

Due to the possibility of potentially uncontrollable bleeding caused by DIC, we elected a non-surgical approach to treatment. In cases presenting with atypical swelling of the tonsils, we recommend a thorough and systematic approach to the diagnosis, including careful consideration of the blood test results, in order to avoid unnecessary surgical treatments.

Laryngomalacia is one of the most common causes of laryngeal stenosis in infants and young children, and many improve spontaneously by the age of 2 years. Acquired adult cases are rare, but most reported cases can be classified into the epiglottic type, using the classification for congenital laryngomalacia. Adult cases are associated with diverse diseases, suggesting the possibility that the pathophysiologic mechanism underlying the occurrence may differ from that in infants.

We report the case of a 22-year-old woman with arytenoid-type laryngomalacia who presented with recurrent episodes of dyspnea. Laryngoscopy revealed loose mucosal folds from both arytenoids entering the laryngeal cavity during inspiration. Resection of the excess mucosa on both sides was performed with an electric knife (Colorado-microdissection needle^®), and the patient’s symptom improved.

We encountered a case of adult-onset laryngomalacia (laryngeal type), which is very rare, in which the symptoms improved after resection of the excess mucosa. Acquired factors such as mucosal fragility and allergy were suspected, and the possibility of laryngomalacia should be considered in patients presenting with recurrent episodes of dyspnea.

IgG4-related disease (IgG4-RD) mainly manifests as a mass or a nodular lesion with IgG4-positive plasma cell infiltration and fibrosis in multiple organs. Comprehensive diagnostic criteria as well as several organ-specific diagnostic criteria for IgG4-RD have been published. Although there are some case reports of cases of Hashimoto’s disease, Riedel’s thyroiditis and Basedow disease with elevated serum IgG4 levels, these cases have not been categorized clearly.

We report the case of a 59-year-old woman who presented with a neck swelling and dyspnea breathlessness. Laboratory examination revealed evidence of hypothyroidism, markedly elevated levels of thyroid autoantibodies, and elevated serum IgG4 levels. We performed total thyroidectomy, and histopathological examination of the respected specimen revealed findings consistent with the diagnosis of IgG4 thyroiditis, including IgG4-positive cell infiltration and fibrosis. The serum IgG4 levels returned to within normal range post surgery.

There is no well-established treatment for IgG4-related thyroiditis until date, and it is necessary to explore effective treatments for IgG4-related thyroiditis.

We conducted a retrospective analysis of the data 107 cases of peritonsillar abscess treated at our hospital between January 2014 and December 2018. Data on the age, sex, affected site, duration of hospitalization, method of drainage, presence/absence of laryngeal edema, antibacterial drugs used, and isolated bacteria were analyzed. Of the 107 patients, 71 were males and 36 were females; the median age was 44 years (range, 18 to 88 years). The left side was affected in 55 patients, the right side in 50 patients, and both sides in 2 patients. The abscess was localized in the superior pole in 71 patients, and in the inferior pole in 36 patients. Thirty-five patients had laryngeal edema, of which 3 underwent tracheotomy. Recurrence of the abscess was observed in 15 cases, with the recurrence developing within 3 months in 7 cases, and over a period of 3 years in 4 cases. As for the sensitivity of the causative bacteria to antibacterial drugs, 17% of the causative bacteria showed resistance to CLDM, while none showed resistance to ABPC/SBT. We concluded that ABPC/SBT might be suitable for the initial treatment of peritonsillar abscess, and that we need to bear in mind the possibility of long-term recurrence.