In recent years, a dramatic rise in the incidence of human papilloma virus (HPV)-associated oropharyngeal cancer has been reported. As compared with non-HPV associated oropharyngeal cancer, HPV-associated oropharyngeal cancer typically shows high susceptibility to radio- and chemotherapy and a better prognosis. Even after initial primary surgery, HPV-associated oropharyngeal cancers are highly curable and carry a good prognosis as compared with non-HPV associated oropharyngeal cancers. Therefore, therapy for HPV-associated oropharyngeal cancers should be selected with the goal of radical cure with good functional outcomes, minimum invasiveness and complications. If complete resection of the tumor with sufficient negative margins could be expected from surgery alone, especially minimally invasive surgery, as the primary treatment option, the treatment period would be dramatically shortened, with great merits. We retrospectively reviewed the data of 29 cases of HPV-associated oropharyngeal cancer of the lateral wall that we treated by surgical resection, focusing on the extent of invasion of the tumor, to identify factors that may affect the resected margins in surgically treated candidates. The margin positivity rate was significantly higher in cases with invasion of the soft palate, base of the tongue and pharyngeal contractile muscles. Multivariate analysis also identified presence/absence of invasion of the pharyngeal contractile muscles as a significant prognostic factor. Based on these results, we recommend that surgery not be considered as the primary treatment option in cases with tumor invasion of the pharyngeal contractile muscles.

For cases without involvement of the pharyngeal contractile muscles, if surgery is opted for instead of radiation therapy, a minimally invasive approach would be desirable. We present the case of a patient with a tumor extending caudally, who was successfully operated by the pull-through method without free flap reconstruction, and is showing a satisfactory good postoperative course.

Among the cases that were treated at the Masaki Jibika Clinic in the past 3 years, 228 that met the diagnostic criteria for migraine were extracted, and the data were examined to determine the association of migraine with vertigo and dizziness, in particular. A retrospective review of the data was conducted to determine the age, gender and main complaint of the patients, presence/absence of aura, presence/absence of vertigo, and presence/absence of headache at the initial visit, and the presence/absence of complications such as Ménière’s disease (MD), benign paroxysmal positional vertigo (BPPV), and tension-type headache. The results showed the 228 cases complained 40 male and 188 female patients, the male:female ratio of 1:4.7 indicating that the majority of the patients were women. The average age was 36.6±14.2 years. Most of the patients were in their 30 s or 40 s, this age band accounting for 46.1% of all the cases. Of the 228 patients, 162 complained of vertigo, and only 27 complained of visual aura. The number of cases in which headache was self-reported without vestibular symptoms at the first visit accounted for 95.5%. On the other hand, the number of cases in which headache was self-reported with vestibular symptoms at the first visit accounted for 59.3%. When the month of the year in which the patients made their initial visits were examined, there were no particular months of the year in which patients without vestibular symptoms initially presented, whereas patients with vestibular symptoms tend to present most often in the month of September and October. Of all the patients, 26 had MD, and of the 26, 9 had vestibular migraine; 60 patients had BPPV, of which 25 had vestibular migraine. Of the 228 patients, 70 had vestibular migraine, 4 had orthostatic dysregulation, and 2 had sudden sensorineural hearing loss. Among the patients with tension-type headache, 10 did not have vestibular symptoms, while 45 had vestibular symptoms, indicating that there were significantly more case with vestibular symptoms among the patients with tension-type headache. Although many facts about migraine and vestibular migraine remain unclear, it is important for otolaryngologists to have a good awareness of these conditions, as a large number of cases present with vertigo. As there were many cases with BPPV in our case series, it is suggested that the relationship between migraine and BPPV be examined in a future study.

Venous malformations rarely occur in the middle ear, especially at the tympanic opening of the Eustachian tube. A 36-year-old female patient who presented with a several months’ history of a clogged-ear feeling on the left side was referred to us for evaluation. Endoscopic examination showed a dark purple mass occupying the anterior-superior quadrant of the left tympanic membrane. A pure-tone audiogram showed normal hearing. Computed tomography showed an isolated lobulated soft tissue mass extending from the tympanic opening of the Eustachian tube extending to the promontory. There was no evidence of bony erosion in the middle ear. The lesion was visualized as a hyperintensity on T1- and T2-weighted images, and as a contrast-enhancing mass lesion on gadolinium-enhanced magnetic resonance imaging. We performed tumor resection via the postauricular approach. The mass was not adherent and could be removed en bloc. The ossicular chain was intact. Histopathologic examination of the resected specimen identified the lesion as a venous malformation. There was no recurrence until the end of the 2-year follow-up period.

Venous malformations are benign vascular tumors that account for 44%–64% of all vascular malformations. About 40% of all venous malformations occur in the head and neck region, although venous malformation of the temporal bone is rare. Furthermore, while it is known to occur in the geniculate ganglion, internal and middle ear, chorda tympani, etc., its occurrence at the tympanic opening of the Eustachian tube has never been reported before. Middle ear venous malformations could be asymptomatic or cause a variety of symptoms, including conductive hearing loss, pulsatile tinnitus, bloody otorrhea, otalgia, and otitis media, in order of decreasing frequency. Our patient presented with only a clogged-ear feeling and there was no conductive hearing loss. This could have been a result of the mass being located at the tympanic opening of the Eustachian tube.

To the best of our knowledge, this is the first documented case of venous malformation arising from the tympanic opening of the Eustachian tube.

Gradenigo syndrome is characterized by the triad of otitis media, trigeminal neuralgia, and abducens nerve palsy, and occurs most often when infection travels from the middle ear spreads to the petrous apex. With advances in diagnostic imaging and appropriate use of antibiotics, this syndrome is rarely seen nowadays. Herein, we report a case of Gradenigo syndrome that occurred in the third trimester of pregnancy and was successfully treated conservatively.

The patient was a 36-year-old woman who presented with the complaint of pain in her left ear and was diagnosed as having otitis media. She underwent left myringotomy at a local otolaryngology clinic and was started on treatment with oral cefditoren pivoxil. Her symptoms did not improve, and she developed diplopia. At the time of her initial visit to us, she was in the ninth month of pregnancy. She had a left ocular abduction disorder, otorrhea in the left ear, and redness and swelling of the tympanum. Detailed imaging examinations, including contrast-enhanced computed tomography, magnetic resonance imaging, and magnetic resonance angiography, revealed left otitis media, sphenoiditis, left petrositis, and left internal carotid artery occlusion due to the spread of inflammation. The patient was hospitalized, a repeat left myringotomy was performed and intravenous ceftriaxone was initiated at 4 g/day, along with ofloxacin eardrop instillation and tympanic cavity irrigation.

Many of the patient’s symptoms resolved in response to this treatment. She was discharged 41 days after admission and gave birth without incident. Later examinations showed bone regeneration in the left petrous apex and disappearance of the sphenoid sinus mucosal thickening.

Proper selection of tests and treatments was difficult prior to delivery in the present case, because of the need to consider their effects on the mother and the fetus. Management of this patient underscored to us the difficulty in managing severe infections during the perinatal period.

Isolated fracture of the malleus is a rare condition and is often caused by typical events, such as sudden withdrawal of a finger from the ear canal. Here, we report a case of isolated fracture of the malleus. The patient, a 36-year-old man, put his finger in the left ear canal and pulled it out suddenly, and immediately developed hearing loss on the same side. His left audiogram showed conductive hearing loss, and isolated fracture of the malleus was suspected based on the typical medical history. We performed transcanal endoscopic ear surgery (TEES) in order to obtain a good view of the tympanic cavity, and fixed the malleus fracture with calcium phosphate bone cement, which has appropriate osteoconductive characteristics. After the surgery, normal hearing was restored in the patient. Calcium phosphate bone cement is a useful material for restoring osteoconductive hearing.

We report a case of phosphaturic mesenchymal tumor arising in the nasal cavity. The patient was a 38-year-old man who presented to his previous doctor with a 3-year history of progressively worsening bone pain. Laboratory examination revealed high blood levels of fibroblast growth factor-23 (FGF23), and the patient was referred to our hospital for further investigation and treatment. Based on our examination findings, we suspected tumor-induced osteomalacia. Systemic venous sampling for FGF23 and ⁶⁸Ga-DOTATOC-PET revealed a tumor in the right nasal cavity as the lesion causing the osteomalacia. Complete removal of the tumor resulted in normalization of the blood FGF23 levels and dramatic improvement of the symptoms.

We treated a patient who presented with the spread of maxillary sinusitis into the orbit through an orbital blowout fracture. A 56-year-old man injured his face when he accidentally fell off a roof. He was diagnosed as having a right orbital blowout fracture at the hospital that he was initially transported to, but as no visual disturbance was evident, conservative treatment was selected. The following day, however, he developed swelling of the right eyelid and diplopia, and was referred to our hospital. We made the diagnosis of rhinogenic intraorbital infection spreading through the orbital blowout fracture site, and performed emergency endoscopic sinus surgery on the same day. Postoperatively, maxillary sinus irrigation was performed and antibiotic therapy was initiated, after which the eyelid swelling gradually improved and the diplopia resolved. There are only a few reported cases of intraorbital infection due to orbital blowout fractures. Early diagnosis and surgical treatment are important in these cases, since delayed treatment could lead to loss of vision.

S-1, an oral 5-FU prodrug, is an antineoplastic agent used for the treatment of various types of cancer, including cancer of the head and neck. In addition to inflammation, infection, trauma, and iatrogenic causes, nasolacrimal duct obstruction could also be caused by S-1. Herein, we report the case of a patient with nasolacrimal duct obstruction that was suspected to be caused by S-1, and was successfully treated by endoscopic dacryocystorhinostomy (DCR). The patient, a 69-year-old woman, was initiated on treatment with S-1 as adjuvant therapy after resection of breast cancer. Four months later, she developed epiphora, and the lacrimal ducts were intubated with silicone tubes. A year later, she presented with recurrence of epiphora, and was referred to our department. We performed right DCR for nasolacrimal duct obstruction, and the epiphora improved. Although the mechanism of nasolacrimal duct obstruction caused by S-1 has not yet been clarified, otorhinolaryngologists should be aware of this condition.

Inflammation of the pharynx or larynx could spread to the surrounding tissues and cause complications, including thrombosis of the internal jugular vein. We report the case of a 63-year-old man who was diagnosed as having peritonsillitis complicated by internal jugular vein thrombosis. He presented to us with marked swelling of his neck. Neck computed tomography revealed absence of blood flow in the right internal jugular vein, which led to strong suspicion of the diagnosis of Lemierre’s syndrome. Ultrasonography revealed a thrombus in the internal jugular vein.

Klebsiella pneumoniae was later isolated from blood cultures. We initiated the patient on treatment with sulbactam sodium/ampicillin sodium (3 g × 4 times a day) and continuous IV heparin, and the symptoms improved. When treating patients with pharyngeal or cervical infections, it is important to bear in mind the potential complication of internal jugular vein thrombosis.

Since complete excision of the fistula tract is essential in surgery for pyriform sinus, identifying the fistula tract is the key to the surgical procedure. However, the tract is often difficult to identify because of complicating infection or small size of the tract in neonatal cases. Herein, we report our experience of attempting to visualize the fistula tracts in two cases of pyriform sinus fistula. In one case, insufflation by upper gastrointestinal endoscopy was used to identify the fistula, and the fistula tract was stained with pyoktanin blue from the fistula opening. In the other case, a neotate, the tract was found as a cyst by magnetic resonance imaging. Direct injection of pyoktanin blue into the cyst enabled easy visualization of the fistula tract, and the surgery was performed successfully. These methods are considered potentially applicable to visualize the fistulous tract in cases of pyriform sinus fistula.

Among soft tissue infections of the neck, necrotizing fasciitis is relatively more likely to lead to serious outcomes due to the prolonged course, and prompt treatment is required. We encountered 4 cases of cervical necrotizing fasciitis in 3 months. The patients consisted of 3 males and 1 female, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was 1 in the low-risk group, 1 in the moderate-risk group, and 2 in the high-risk group. Among the patients, the low-risk group patients showed abscess formation in the longitudinal direction over time and required surgical treatment. In addition, some cases required plastic surgery at a university hospital due to inadequate wound healing associated with the underlying disease, and cases in which the surgical procedure could not be completed due to the underlying disease had unfortunate outcomes. Early antimicrobial administration and extensive necrotic tissue removal by debridement were required in all the cases. Age and presence/absence of the underlying disorder also influenced the course of the condition. Although the LRINEC score is useful for risk assessment in patients with cervical necrotizing fasciitis, it has been reported that the cervical necrotizing fascia inflammation spreads in the longitudinal direction in about a half of the cases. Our clinical experience underscored to us the importance of monitoring the course of the subjective symptoms and multiple blood test results, and image evaluations.

Deep neck abscesses are relatively rare in pediatric patients and can lead to critical complications. The characteristics of deep neck abscesses in pediatric patients differ from those in adult patients, and inflammation often spreads through the lymphatic route in children. In this study, we reviewed 5 pediatric cases of cervical abscess at our hospital between January 2017 and December 2018, that required open drainage. No serious complications, such as airway narrowing or mediastinal abscess were encountered. In some cases, imaging examinations revealed abscesses in the draining lymph nodes.

In children, inflammation often spreads through the lymphatic route to form abscesses in the lymph nodes, a feature that differs from adult cases. In our cases, abscess formation was also observed in the posterior cervical space and submandibular space on the CT images. There are relatively few previous reports of severe complications of pediatric deep neck abscesses, and consistent with previous reports, no serious complications, such as mediastinal abscess and airway obstruction, were observed in our cases either. Pediatric cases are easy to control by conservative treatment, but incision and drainage were performed in our cases because of resistance to antimicrobial treatment. The condition resolved without serious complications in all our cases.

Deep neck abscesses occur as a result of spread of infection from the soft tissues to spaces in the head and neck, and can progress to descending necrotizing mediastinitis (DNM). DNM is a serious condition with a high mortality. A case of deep neck infection complicating DNM is described in the present report.

The patient was a 55-year-old woman who visited a nearby otolaryngologist complaining of a 3-day history of gradually worsening sore throat. Physical examination revealed swelling of the posterior wall of the pharynx, and retropharyngeal abscess was suspected.

The patient was referred to our department for further examination and treatment. Computed tomography revealed abscess formation mainly in the retropharyngeal space. Despite treatment with antibiotics, the abscess worsened and progressed to DNM. Surgical drainage of the neck and thoracic cavity was performed twice. Because the DNM failed to improve even after the surgical drainage, negative pressure wound therapy with instillation and dwelling (NPWTi-d) was initiated. With the NPWTi-d, the abscesses gradually reduced in size, and the patient was discharged from the hospital.

NPWT is a treatment that promotes wound healing by sealing the wound surface and applying continuous negative pressure. In addition to negative pressure, NPWTi-d has an automatic cleaning function, and can be used for wounds with incomplete debridement. NPWTi-d was highly effective in this case, in which the infection continued to progress even after drainage and antibiotic administration. The patient was later diagnosed as having advanced rectal cancer, which was considered as possibly having had an effect on the disease aggravation and intractability. In addition to promoting wound healing, NPWTi-d saves time by obviating the need for frequent dressing. NPWTi-d is considered as a useful treatment for infected wounds that fail to respond to usual treatments such as drainage and antibiotic treatment.