Following the use of paraffin injection by Brunings in 1911, various materials, such as Vaseline and Teflon liquid silicone, have been used for injection laryngoplasty. In Japan, atelocollagen, hyaluronic acid, autologous fat, and calcium phosphate cement (CPC) have recently been used as injection materials. Each material has some limitations, including the risk of induction of foreign body reaction, formation of granulation tissue, risk of infection, and need for harvesting autologous tissue. In this article, we provide a general review of injection laryngoplasty and our novel technique of videolaryngoscopic injection laryngoplasty using CPC.

The authors have performed an injection laryngoplasty using CPC since 2002. CPC is a commercially available bone graft substitute which changes within a few minutes after injection into a calcium hydroxyapatite (CaHA) block. Its quick hardening property makes it possible to fix the arytenoid cartilage in an adducted position during laryngoplasty. Recently, we developed this surgery as a novel transoral videolaryngoscopic injection laryngoplasty. The tips of our technique are 1) exposure of the surgical field of the posterior glottis using a distending laryngoscope (FKWO retractor) and HD videoendoscope with an articulating tip (Endoeye flex), 2) simulation of arytenoid cartilage medialization by manual pushing of the muscular process of the arytenoid cartilage from the pyriform sinus side, and 3) fixation of the arytenoid cartilage by the same procedure as that described in 2) above.

The results demonstrated significant improvement of the vocal function and the glottic gaps on CT images in patients with a large glottal gap. This simple and less invasive technique has the potential to become an alternative procedure to laryngeal framework surgery.

Background: Allergen immunotherapy is the only curative treatment for allergic rhinitis (AR) that can induce long-term clinical remission. In Japan, sublingual immunotherapy (SLIT) is often employed for the treatment of AR caused by Japanese cedar pollen (JCP) and house dust mites (HDM). To obtain a high likelihood for remission, SLIT should be continued for at least 3 to 5 years; however, a substantial number of patients dropout from the treatment.

Objective: The aim of this study was to examine what proportion of patients successfully continue SLIT for at least 3 years for AR caused by JCP and/or HDM, and to identify factors affecting dropout from SLIT at Makinohara Nanohana ENT Clinic, Japan.

Patients and Methods: In total, 123 patients (aged 12 to 76 years) who were started on SLIT (JCP: 44 patients; HDM: 48 patients; both: 31 patients) between May and December 2017 were included in the study. SLIT was administered according to a standard schedule, although the allergen dose was reduced in cases with severe adverse reactions.

Results: Among the 123 patients, 46 (37.4%) adhered to the SLIT for at least 3 years. The incidence of severe reactions was higher in patients receiving SLIT for HDM (31 patients (39.2%)) than in those receiving SLIT for JCP (10 patients (13.3%): p = 0.0002). Although the occurrence of adverse reactions did not affect the dropout rate, the dropout rate was significantly higher among those patients in whom the dose of the allergen had been reduced (p = 0.039).

Conclusions: Dose reduction of the allergen because of the occurrence of severe adverse reactions may be a factor contributing significantly to dropout from SLIT.

We report a rare case of an implant being discharged through the nasal cavity after endoscopic sinus surgery for odontogenic sinusitis caused by the implant. A 74-year-old Japanese woman who presented to us with a 3-month history of postnasal drip and left nasal obstruction had undergone a dental implant at the site of the upper left maxillary second molar 16 years prior to her first visit to our department; a panoramic radiograph obtained at our Department of Dentistry 5 years earlier revealed bone resorption around the implant. At the present visit, the implant was found to be projecting above the floor of the left maxillary sinus, and sinus computed tomography (CT) revealed areas of soft tissue density in the left maxillary sinus and ethmoid sinus and around the implant. Based on the above findings, we made the diagnosis of odontogenic sinusitis related to the implant. We performed endoscopic sinus surgery (ESS), and found drainage from the maxillary sinus and swelling of the mucosa. However, we found no implant at the site of the upper left maxillary second molar, and the patient gave no history of implant removal. Her symptoms disappeared 61 days postoperatively. In a sinus CT obtained 6 months after the ESS, the area of soft tissue density lining the left maxillary sinus was thinner than that found in the sinus CT obtained 3 months after ESS. Finally, the implant was discharged through her nasal cavity 9 months after the ESS.

Orbital apical syndrome is a disorder of the apical portion of the orbit that causes damage to the oculomotor nerve, trochlear nerve, first branch of the trigeminal nerve, abducens nerve, and optic nerve, resulting in symptoms such as eye movement disorder, eyelid drooping, and visual impairment.

There are various causes of orbital tip syndrome, including inflammatory diseases such as sarcoidosis and IgG4-related diseases, infections of viral or fungal origin, trauma, and neoplastic lesions such as nasopharyngeal carcinoma, and many cases are difficult to diagnose.

In this article, we present a case of orbital tip syndrome that was caused by a posterior ethmoid sinus cyst in a 63-year-old man.

The patient had no underlying medical condition and presented with eye pain, diplopia, and decreased vision.

An MRI revealed a sinus cyst, and the patient underwent endoscopic sinus surgery.

No fungal infection was suspected from the histopathological findings. Both the diplopia and visual disturbance improved postoperatively.

Orbital apex syndrome derived from a sinus cyst is associated with few nasal symptoms. It is important to obtain an early diagnosis and provide prompt treatment in collaboration with other departments.

We present the case of a patient who was diagnosed preoperatively as a case of eosinophilic chronic rhinosinusitis with supra agger frontal cell (SAFC) cyst. In fact, there was no cyst, but rather bone thinning of the anterior cranial floor caused by nasal polyps. Therefore, the cyst wall was perforated, but it was actually the dural membrane, and spinal fluid leakage occurred. Intraoperative MRI was used to minimize complications. The dura was repaired using a free mucosal flap and the postoperative course was satisfactory. Even polyps, such as in case of eosinophilic chronic rhinosinusitis, can cause thinning and loss of bone in the skull base, and intraoperative MRI, which can confirm dural membrane damage and anatomic location, is useful if such a finding is present.

Infections by the coccidian parasite Toxoplasma gondii usually do not cause obvious symptoms in adults. Lymphadenopathy is the most common clinical manifestation of acute acquired toxoplasma infection in healthy individuals, but rarely presents as a parotid mass. Herein, we report a case of multiple masses in the parotid region caused by toxoplasmosis. A 35-year-old woman had visited another hospital with a one-month history of preauricular swelling. Computed tomography and magnetic resonance imaging revealed multiple masses in the left parotid region and bilateral cervical regions. Fine-needle aspiration cytology from the parotid mass did not reveal any evidence of malignancy. Histopathological examination of an excised lymph node from the right submandibular region revealed follicular hyperplasia, monocytoid B-cell proliferation, and granuloma formation. Serological tests revealed high serum levels of both IgM and IgG antibodies against Toxoplasma gondii. Based on the findings, we made the diagnosis of toxoplasmic lymphadenitis. The lymphadenopathy gradually subsided through six months of follow-up.

Toxoplasmic lymphadenitis has few characteristic findings, but toxoplasma infections should be included in the differential diagnosis of massive swellings in the salivary gland area.

We report a case of chronic thyroiditis with upper airway obstruction associated with myxedema.

The patient, a 68-year-old man, presented to our emergency room on Saturday evening with complaints of dysarthria and wheezing since the same morning. After securing the airway with a nasal airway, the patient was referred to the on-call otolaryngologist.

CT showed no obvious abscess. The patient had marked edema and stenosis at the oral and middle pharyngeal levels and redness and swelling of the face, suggestive of infection or angiogenic edema.

Prophylactic tracheostomy was recommended because of the anticipated difficulty in intubation, but the patient refused consent. Therefore, we treated the patient with a steroid and antibiotics and decided to observe the patient with a nasal airway in place. In the middle of the night, the patient’s respiratory condition worsened and an emergency tracheostomy was performed.

Subsequently, clinical examination and further work-up revealed extreme hypothyroidism and chronic thyroiditis were found, and the upper airway obstruction was thought to be caused by myxedema. The neck swelling improved after administration of thyroid hormones, and the tracheostomy was closed.

Hypothyroidism with myxedema is known to be associated with obesity and hypoventilation. In severe cases, respiratory failure with hypercarbia may occur. In this case, in addition to respiratory failure, the upper airway obstruction may also led to the need for securing the airway.

In the treatment of early-stage tongue cancer, brachytherapy has been considered a good indication of the point of preserving shape and function. In recent years, the number of long-term survivors after radiotherapy has increased, and secondary cancers in the irradiated field have begun to attract attention. Herein, we report here on two cases of radiation-induced cancer of the tongue developing after brachytherapy.

Case I: A 59-year-old woman who had undergone brachytherapy for right tongue cancer 20 years earlier, and had passed without recurrence in the intervening period presented with. She felt a burning sensation on her tongue, and was diagnosed by biopsy as having squamous cell carcinoma.

Case II: A 48-year-old woman had undergone brachytherapy for left tongue cancer 22 years earlier. She underwent neck dissection and postoperative radiotherapy for delayed emergence of regional recurrence 5 months after the brachytherapy. She had had no recurrence in the intervening period since then until her present visit when a physical examination revealed induration at the left tongue margin, and she was diagnosed by biopsy as having squamous cell carcinoma.

It is extremely difficult to distinguish between late recurrence and radiation-induced cancer in cases presenting with secondary cancers after radiotherapy. In these two cases described above, the secondary cancers developed within the irradiation field of the radiotherapy administered for primary cancer, and there was no evidence of cancer in other tissues between primary cancer and the current secondary cancer. Therefore, we considered that it might be more appropriate to diagnose it as radiation-induced cancer rather than as late recurrence or field carcinogenesis. Although the local control rate of brachytherapy for early-stage tongue cancer is comparable to that following surgical treatment, long-term follow-up is necessary because of the possibility of secondary cancer developing in the irradiation field, as in the cases reported herein.

Bilateral adrenal hemorrhage (BAH) is a rare but potentially fatal disease. BAH is associated with sepsis, antiphospholipid syndrome, use of anticoagulants, adrenal tumors, including metastases, or trauma/surgery in most cases. Mucositis induced by radiation therapy is a frequently occurring toxicity in patients with laryngeal cancer. However, it is rare for radiation-induced mucositis to be complicated by sepsis. We report the case of a 76-year-old man who was diagnosed as having laryngeal cancer (cT2N0M0), received radiation therapy, but suffered from septic shock and died immediately after the radiation therapy. Bacterial culture revealed the growth of Enterobacter cloacae from both the oral discharge and blood. Autopsy revealed severe mucositis, disseminated intravascular coagulation, and bilateral adrenal hemorrhage, and the patient was diagnosed as having died due to acute adrenal failure caused by bilateral adrenal hemorrhage.

Retropharyngeal hematoma is caused by trauma and can cause dyspnea as a result of upper airway obstruction. Therefore, appropriate diagnosis and prompt treatment are important. We report the case of a patient with no underlying disease, who developed a retropharyngeal hematoma caused by neck flexion.

A 23-year-old man was referred to our department with dyspnea that developed after he exercised his abdominal muscles. We performed tracheostomy immediately, because the airway was significantly narrowed by a retropharyngeal hematoma. The hematoma eventually resolved with conservative treatment. Airway protection is important in patients with a retropharyngeal hematoma. Therefore, otorhinolaryngologists should immediately perform tracheostomy. Hematomas can resolve with conservative treatment; however, surgical treatment is necessary for hematomas that rapidly increase in size or hematomas that do not improve within 2 weeks.

This disease is an emergency medical condition with a high risk of airway obstruction. Otorhinolaryngologists should be aware that even mild neck flexion can cause severe airway obstruction. Appropriate diagnosis and prompt airway management are important.

Ameloblastoma is a rare disease in encountered in the field of otolaryngology, but it is the most common odontogenic tumor. Most ameloblastomas occur in the mandible; moreover, as they are histologically benign, they show slow growth. However, it should be noted that they can proliferate and infiltrate the surrounding tissues, and rarely also show malignant transformation. We report a case of maxillary ameloblastoma that showed rapid growth.

A 20-year-old man visited our department with complaints of right nasal congestion and swelling of the right cheek. A computed tomographic (CT) examination performed one year earlier revealed a cystic lesion in the right maxillary sinus, but the repeat CT examination revealed a cystic mass centered on the right maxillary sinus with bone defects in the inner, outer, and upper (orbital floor) walls of the maxillary sinus. Endoscopic sinus surgery (ESS) was performed in order to diagnose the tumor and relieve the pressure on the surrounding tissues. Cyst wall fenestration was performed, and the inner cyst wall and a solid component from the bottom of the right maxillary sinus were biopsied. Histopathology of both the inner cyst wall and the solid component confirmed the diagnosis of ameloblastoma. Because of the possibility of extensive tumor resection if the tumor had been adherent to the surrounding tissues, we decided to follow up with the patient after explaining that while ameloblastoma generally grows slowly, it is possible for it to grow rapidly. However, six months after the ESS, the solid component had enlarged and cyst recurrence was identified. A Caldwell-Luc surgery was performed under general anesthesia and the tumor was resected completely.

Ameloblastoma is a benign tumor, but its recurrence is common. Even for cases of unicystic ameloblastoma, removal alone does not provide sufficient cure, and conservative treatment is often adopted. We recommend aggressive management for lesions that enlarge rapidly and recur within a short time period.

Pharyngo-esophageal stricture occurs as an adverse event after chemoradiation therapy for head and neck cancer, although complete obstruction is rare. The patient’s quality of life is impaired due to the difficulty in food intake and in swallowing saliva. Endoscopic balloon dilatation and stent insertion have been used for their treatment, but there is still no consensus on the optimal treatment. We report a case in which we were able to release the obstruction by inserting an endoscope through the mouth and the gastrostomy. The patient, a 47-year-old man, was diagnosed as having Stage III squamous cell carcinoma of the mesopharynx (T4N1M0). Because the result of induction chemotherapy was SD (stable disease), we performed tumor resection and administered postoperative chemoradiation therapy. Gastrostomy was performed because swallowing dysfunction was observed at the completion of the post operative radiation sessions. One year later, while imaging studies showed no recurrence of the disease, the swallowing function had not improved at all. We conducted video fluorography and gastroscopy to determine the cause, and detected pharyngo-esophageal obstruction. We attempted to release the obstruction endoscopically in the hope of preserving the vocal functions. We chose to use a dual approach via the mouth and the gastrostomy. The adhesion site of the pharynx and the esophagus was incised with a hook knife while observing from the gastrostomy side. The adhesions were dissected and the proximal and distal sides were opened. Balloon dilatation training was undertaken after the operation. The patient is now able to take liquids and semi-solid foods orally, but nutrition via the gastrostomy was continued. Clearing the obstruction did not completely resolve the dysphagia and treatment of the velopharyngeal insufficiency was necessary in this case. Therefore, the choice of treatment should be based on the wishes of the patient, clinical situation, and the nature of the treatment for the primary disease.

Granulomatosis with polyangiitis (GPA) is characterized by systemic vasculitis with necrotizing granulomatous inflammation and pauci-immune small-vessel vasculitis. The initial symptoms are usually nasal or paranasal sinus lesions, and GPA with parotid swelling is rare. We report the case of a patient who presented with a parotid swelling, who was finally diagnosed as having GPA.

A 72-year-old man presented with a large mass measuring 30 mm in diameter in the left parotid gland with indistinct borders and contrast enhancement. Fine-needle aspiration (FNA) cytology revealed no evidence of malignancy. Chest CT showed multiple nodular shadows with spicula in the lower lung lobes bilaterally, suggestive of pulmonary metastases from parotid carcinoma. Transbronchial biopsy showed an inflammatory cell infiltrate consisting mainly of lymphocytes and histiocytes, with necrosis. Therefore, we suspected vasculitis and performed serology for ANCA, which revealed a PR3-ANCA titer of 74.3 U/mL. After a second otorhinolaryngological screening, left otitis media with effusion was diagnosed. We made the diagnosis of GPA and started the patient on remission induction therapy. After the treatment, the test for PR3-ANCA became negative and the parotid and pulmonary lesions showed marked resolution.

GPA with parotid involvement is rare, and delays in diagnosis are common. Early diagnosis and treatment are important because early treatment is associated with a high likehood of remission. Therefore, we considered it advisable to screen the otorhinolaryngological and pulmonary areas and perform additional close examination in patients presenting with a parotid swelling, considering the possibility of GPA.

Concurrent chemoradiotherapy (CRT) is one of the standard treatment strategies for patients with locally advanced head and neck squamous cell carcinoma (HNSCC). Prophylactic percutaneous endoscopic gastrostomy (pPEG) has been reported to be useful for nutritional intervention during CRT. On the other hand, disadvantages such as complications of gastrostomy itself and long-term PEG dependence have also been reported. In the present study, we conducted a retrospective review of the data of HNSCC cases treated with CRT and re-evaluate the merits and demerits of pPEG.

Patients with pharyngeal carcinoma treated by CRT between 2015 and 2020 were enrolled for this analysis. In this study, we limited our analysis to those who received the following treatments: Radiation therapy was planned for a total dose of 70 Gy, and the concomitant chemotherapy regimen was high-dose (100 mg/m²) CDDP administered intravenously once every three weeks (3 cycles).

A total of 54 patients who underwent pPEG, met the inclusion criteria. Fifteen patients who had received similar treatment without pPEG during the study period were used as a control group for comparison.

The results revealed that in the pPEG group, there were fewer cases with a weight loss of 10% or more, nutritional intervention was started relatively early, and the hospitalization period after the end of CRT was shorter as compared with the status in the non-PEG group. In regard to PEG tube dependence, the rate of PEG tube usage at 6 months after CRT was relatively low, at about 13%. No significant factor was identified in this study regarding the need for nutritional intervention by routes, including PEG tube, nasogastric tube and TPN, other than oral intake.

In the review of the literature, it seemed difficult to make a simple comparison due to the lack of uniformity in the selection criteria for pPEG, patient background, and treatment intensity.