Chronic rhinosinusitis (CRS) is divided into CRS with nasal polyp formation (CRSwNP) and CRS without NP formation (CRSsNP) according to the phenotype classification. CRS is also divided into type 1/type 2/type 3 according to the endotype classification. CRSwNP and type 2 CRS are caused by eosinophilic inflammation in most cases, and are intractable. Useful biomarkers for such cases of eosinophilic CRS (eCRS) are desired for predicting their severity and postoperative courses.

In our recent study, we demonstrated that the number of IgG4-positive cells in the NP tissue and serum IgG4 levels could be potential novel biomarkers for evaluating the disease severity and predicting the risk of postoperative recurrence in cases of eCRS. Combined use of serum IgG4 and serum periostin levels can further improve the predictive ability.

Traditionally, peripheral blood eosinophilia and tissue eosinophilia have been used as biomarkers of eosinophilic inflammation. These biomarkers are used as diagnostic markers in the JESREC study. Charcot-Leyden crystals (CLCs), which are formed from galectin-10 released after extracellular trap cell death (ETosis) of activated eosinophils, also reflect eosinophilic inflammation.

Nasal nitric oxide (nasal NO) can also be a noninvasive biomarker of eCRS. NO is constantly produced in the nasal and paranasal cavity, and nasal NO levels are much higher than fractional exhaled nitric oxide (FeNO) levels. Nasal NO is reduced in eCRS patients, although the mechanism of this reduction has not yet been clarified.

Other biomarkers, such as IgE and leukotriene (LT) levels have been reported to be associated with the severity of eCRS and the risk of postoperative recurrence. The efficacy of anti-IgE antibody and LT receptor blockers in patients with eCRS suggests that IgE and LT receptors are important factors in the pathogenesis of eCRS.

I would like to emphasize here that rhinologists should use noninvasive biomarkers wisely to better manage patients with eCRS.

In the era of the super aging society, with the increasing number of patients with age-related hearing loss, there is a high demand for hearing aids. Furthermore, recent reports of the existence of an association between hearing loss and progression of dementia underscore the importance of fulfilling the needs for hearing aids. Our institute, a core hospital in the aging community, started a specialized outpatient clinic for prescribing hearing aids in 2017. In this study, we analyzed the accumulated clinical data of 178 patients who came to the clinic between October 2017 and December 2020. While a total of 154 patients (87%) were willing to start using hearing aids at the first visit, only 99 patients (55%) finally purchased hearing aids. The patient background characteristics were not significantly different between patients who purchased and did not purchase hearing aids, whereas the motivation for wearing hearing aids and the number of visits required for determining whether hearing aids should be worn or not were significantly higher among patients who finally purchased hearing aids. The top three reasons for not purchasing hearing aids were 1) not feeling the necessity (28%), 2) financial difficulties (22%), and 3) inability to adapt to hearing aids (18%). Although our institute introduced hearing rehabilitation, the proportion of patients who purchased hearing aids was relatively low as compared with previous reports; that could be attributable to the lack of systematic operation of the specialized outpatient clinic, including absence of established criteria to determine the duration of rehabilitation and lack of cooperation with speech therapists. On the other hand, the patient’s motivation and financial support were highly important for successful starting of hearing-aid wearing, considering the reasons for dropout from treatment. Taken together, establishing a protocol for hearing rehabilitation and patient education for hearing loss are important for improving the success rate in hearing aid treatment.

The most common injury of the ossicle chain is traumatic incudostapedial joint dislocation. Cases of fracture of the incus or stapes have also been reported, but malleus fracture without injury of the tympanic membrane or other ossicles is rare. Our patient was a 56-year-old man who presented to our outpatient department with an 8-day history of right hearing loss at the time of waking up. On examination, the anterior part of the right tympanic membrane looked dark purple. Pure-tone audiogram showed mid-to-high frequency conductive hearing loss on the right side. A temporal bone CT showed no obvious fracture of the ossicles, but an opacity was noted anterior to the malleus handle, suggesting middle ear hemorrhage. Eight months later, endoscopic ear surgery was performed. The fracture was located near the lateral process of the malleus, and a tragus cartilage graft was placed between the malleus and the tympanic membrane. Postoperatively, the right conductive hearing loss improved. Although isolated malleus handle fracture is rare, it is necessary to keep in mind the possibility of such ossicular bone injuries in daily practice.

Objectives: The purposes of this study were to determine what each of the nasal resistance values means and which nasal resistance values reflect the degree of nasal congestion, and to examine which factors are correlated with the severity of obstructive sleep apnea (OSA), and how oral breathing affects OSA.

Methods: The correlations among the nasal resistance values obtained by anterior rhinomanometry (inspiration, expiration, bilateral, ipsilateral, laterality) were examined in 613 cases diagnosed as having OSA. Correlations of the nasal resistance values with the oxygen desaturation index (ODI)_3% and anthropometric measurements, the morbidity period of snoring, and the period of apnea obtained from a questionnaire were investigated. The patients were then classified into three groups according to the degree of nasal congestion (often, sometimes, never), and the breathing route (oral, oronasal, nasal) obtained from the questionnaire and each of the factors were compared among the groups.

Results: Higher values and lower values of nasal resistance were positively correlated with the laterality and bilateral values, respectively (p < 0.001). The ODI_3% was positively correlated with the BMI, cervical circumference, and morbidity period of snoring and period of apnea (p < 0.001), but not with any of the nasal resistance values. Laterality of nasal resistance during inspiration and the proportion of oral-breathing patients were higher in the often-nasal congestion group (p < 0.001). The onset of snoring was significantly earlier in the oral-breathing group than in the other groups (p < 0.001).

Conclusion: The laterality of nasal resistance during inspiration reliably indicated the severity of nasal congestion. The morbidity period of snoring and that of apnea were both correlated with the ODI_3%, which suggests that repetitive snoring and apnea over the long term might contribute to the severity of OSA. There was no correlation between any of the nasal resistance values and the ODI_3%. The onset of snoring at a young age was related with oral breathing, which might cause OSA.

CT has become the main imaging modality for nasal bone fractures, and CT is increasingly used even for minor nasal bruising in young and pediatrics patients, increasing their risk of excessive radiation exposure. There are numerous reports of the usefulness of ultrasonography for the diagnosis of nasal fractures, because of the simplicity of this diagnostic tool and avoidance of radiation exposure. In this study, we compared the usefulness of ultrasonography and CT/3D-CT in 13 young and pediatric patients who presented with nasal bruising. The children ranged in age from 5 years 10 months to 17 years 5 months. There were 9 boys and 4 girls; 10 patients had nasal fractures and there were no cases in which nasal fractures could not be confirmed by ultrasonography; 6 cases were judged as requiring repositioning based on the external appearance. The size of the deviated bone and the deviation distance in the cases that required repositioning were larger than those in the cases that did not require repositioning. 3D-CT was the most useful imaging test for nasal fractures. Ultrasonography can be used as a screening tool for young and pediatric patients to avoid radiation exposure. However, it appears to be difficult to make a decision on the need for repositioning using ultrasonography alone.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener’s granulomatosis, is a rare anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. GPA in childhood is very rare, so that early diagnosis is difficult in pediatric patients. We report the case of a 14-year-old boy who presented with rapidly progressive disease. He was referred to our department with persistent severe right orbital pain and nasal obstruction despite receiving medication for a month. Right-sided sinusitis and bilateral orbital masses were confirmed on computed tomography (CT) and magnetic resonance imaging (MRI), and endoscopic sinus surgery was performed both the purpose of treating the sinusitis and performing biopsy. Histopathological examination revealed findings suggesting non-specific inflammation of the sinus, while the orbital pain and eyelid swelling continued to worsen, the sinusitis persisted, and the patient also complained of cough. As we suspected GPA, we performed biopsy of the right orbital mass and nasal septal mucosa, and also serology for PR-3 ANCA. As the histopathological results were typical of GPA and serology for PR-3 ANCA was positive, the patient was diagnosed as having GPA three weeks after his first visit to our hospital. The prognosis of GPA is very poor, with 90% of patients dying within a year if left untreated. As early diagnosis and start of treatment are crucial, the attending physician shohld have a high index of suspicion for GPA, even in pediatric patients.

We report a case of pneumoparotitis with extensive mediastinal emphysema. The patient was a 9-year-old boy who presented with swelling and pain on the left side of the cheek. Palpation revealed a snowgrasping feel on the cheek and neck. Computed tomography (CT) showed extensive emphysema, extending from the parotid gland and deep neck to the mediastinum, and we diagnosed pneumoparotitis with pneumomediastinum. The patient was started on treatment with antibiotics to prevent secondary infection and prescribed bed rest. The symptoms gradually disappeared and there was no recurrence of symptoms, suggesting the presence of pneumoparotitis. Pneumoparotitis is rare and can be diagnosed by clinical examination and imaging. For accurate diagnosis, otorhinolaryngologists should take a detailed medical history, and CT is effective for diagnosing, evaluating the disease progression, and deciding the appropriate treatment strategy.

Tonsillectomy is the most commonly performed in pediatric surgery in the field of otolaryngology. In Japan, children who undergo tonsillectomy are generally hospitalized for approximately one week after the surgery. On the other hand, in Europe and the United States, day-care admission or overnight hospitalization has become established for children undergoing tonsillectomy. It has become clear by now, that the risk of complications does not differ significantly depending on the length of hospitalization.

For this study, we enrolled 169 children (114 boys and 55 girls) who had undergone tonsillectomy between January 2015 and January 2021 at the Department of Pediatric Otorhinolaryngology, Hokkaido Medical Center for Children Health and Development. To determine the minimal and optimal duration of hospitalization for children after tonsillectomy, we examined the following parameters; postoperative time to resumption of oral intake, presence/absence of postoperative hemorrhage, and distance from this hospital to the place of residence.

The results showed that the average postoperative time to resumption of oral intake was 2.0 days and the average postoperative length of hospitalization was 3.5 days, which were very short; the incidence rates of early and late postoperative hemorrhage were 1.2% and 0.6%, respectively, lower than the rates reported in past literature.

We concluded that it is possible to shorten the postoperative length of hospitalization. It is important to set the optimal postoperative length of hospitalization in consideration of the general condition and social background of the children.

[Introduction] Desmoid tumors are benign, fibrous, soft-tissue tumors that arise from the connective tissue of the skeletal-muscles, myofascia, and aponeuroses, but rarely develop in the head and neck region. Herein, we report a patient with desmoid tumor of the larynx who was treated total laryngectomy.

[Patient] A 74-year-old male patient underwent laryngeal microsurgery for glottic cancer on the right-side (cTisN0M0). One year after the surgery, we detected swelling of the right vocal fold, and suspected recurrence of the cancer. Therefore, we performed laryngeal microsurgery to remove the right vocal fold. Histopathology revealed only scar tissue, and no evidence of any neoplastic lesion. The patient was then followed up at the outpatient department. However, the patient presented with breathing difficulty and was detected to have hypertrophy of the right vocal fold. Therefore, two years after the initial surgery, we performed tracheostomy. As with the previous biopsy, a tissue biopsy performed at this time again revealed no evidence of malignancy. The thickened tissue was extremely hard and scarred, making laryngeal microsurgery for total removal difficult. However, the right vocal fold continued to thicken gradually, eventually resulting in complete airway obstruction and dysphagia. CT examination revealed some low-density areas extending from the right vocal fold to the deeper areas. Four years after the initial surgery, therefore, we performed total laryngectomy. The histopathological diagnosis was desmoid tumor.

[Conclusion] The risk factors for desmoid tumors include traumatic factors, such as surgeries and fractures, and genetic factors. In our patient, it seems like the initial laryngeal microsurgery triggered the development of a desmoid tumor. We performed total laryngectomy because a sufficient resection margin was required. Many cases of recurrence of desmoid tumor have been reported; therefore, continuous follow-up of such cases is required.

We report a case of lymphoepithelial cysts (LECs) of the thyroid gland that was treated by surgery at our institution. LECs are cystic lesions recognized in the head and neck region, that have been assumed to originate from embryonic remnants. Microscopically, the cysts are usually lined by squamous or squamoid epithelium, occasionally accompanied by ciliated columnar epithelium and mucous cells. The cyst wall contains abundant lymphoid tissue with germinal centers. LECs predominantly occur along the lateral neck, especially along the inside of the sternocleidomastoid muscle, when they are called lateral cervical cysts. LECs of the thyroid gland have been very rarely reported, but since they have the same histological features as lateral cervical cysts, some reports suggest that they also arise as a result of embryonic malformations. However, it still remains controversial as to whether LECs are derived from embryonic remnants or as a result of acquired inflammatory changes of pre-existing tissues. We considered that in our case, the epithelial component of the cysts developed as a result of squamous metaplastic change of thyroid follicular cells rather than from embryonic remnants.

Airway foreign bodies may cause recurrent pneumonia and atelectasis, which could be fatal; therefore, early diagnosis and removal are important. We report the case of a 76-year-old man who underwent total laryngectomy for laryngeal cancer (cT3N0M0) who presented with a foreign body (T-tube) lodged in his airway. Postoperatively, the permanent tracheostomy was observed to be stenotic, and we inserted a T-tube to maintain patency of the tracheostomy. We observed a gradual increase in sputum accumulation, necessitating frequent suctioning. Follow-up computed tomography performed a few weeks later for comorbid interstitial pneumonia revealed a foreign body in the left main bronchus. We performed bronchoscopy for removal of the bronchial foreign body, which proved to be the T-tube.

Although a T-tube is conventionally used to maintain a permanent tracheostomy, it is not approved for maintenance of permanent tracheostomy patency.

The T-tube is a simple and convenient device used in surgical practice; however, surgeons should be mindful of the risks and complications of T-tube lodgment in the airway.

For differential diagnosis of cervical lymphadenopathy, blood tests, imaging examinations, and fine needle aspiration cytology (FNAC) are usually performed, but sometimes, even these tests sometimes do not lead to the correct diagnosis.

We retrospectively reviewed the data of 96 patients who underwent open biopsy of the cervical lymph nodes at our department between January 2015 and August 2018. The patients consisted of 45 men and 51 women ranging in age from 21 to 94 years. We retrospectively divided the patients into three groups on the basis of the final diagnosis (malignant lymphoma, metastatic malignancy, and inflammatory disease), and compared the age distribution, distribution of the final diagnosis, blood test results, imaging findings, and FNAC findings among the groups.

Both malignant lymphoma and metastatic malignancies were common in patients in their 70s. Patients with inflammatory diseases were statistically significantly younger than the patients in the other two groups. There was no significant difference in the mean age between the malignant lymphoma and metastatic malignancy groups.

Of the total, 69 patients were referred to us from within the hospital and 27 cases were referred from outside. The most common referral source from our hospital was the department of hematology (38 cases) and that from outside was to the department of otolaryngology (15 cases). The mean white blood cell count was significantly higher in patient group with metastatic malignancy than that in the patient group with malignant lymphoma. The mean serum LDH levels were not significantly different among the 3 groups. The mean serum sIL-2R level was significantly higher in the malignant lymphoma group than in the metastatic malignancy group. All but 1 of the 22 patients with a serum sIL-2R level of over 2000 IU/L had malignant lymphoma. The most common imaging examination performed before lymph node biopsy was CT in 92 patients, US in 40 patients, MRI in 31 patients, and PET/CT in 27 patients.

FNAC was performed in 45 out of the 96 patients. Papanicolaou staining of the cytology smears revealed a class IV or higher result in the metastatic malignancy group and a class III or lower result in the inflammatory disease group. If a malignant tumor could be ruled out prior to an open biopsy, it is recommended to perform FNAC if possible.

Although the results of FNAC were always benign, the results could include some cases of malignant lymphoma. In other words, if malignant lymphoma is suspected based on the clinical or laboratory findings, open biopsy should be considered. In addition, if it is difficult to distinguish from inflammatory diseases such as Kikuchi disease, which is common among young women, FNAC should be performed first. If malignancy cannot be ruled out clinically, it is desirable to perform core needle biopsy (CNB) before performing an open biopsy, from the viewpoint of cosmetology, especially as immunostaining, which has become the mainstream for the diagnosis of cancers of unknown primary, can be performed on specimens obtained by CNB. In the future, CNB should be selected to avoid the risk of malignant cell dissemination.

This is a report of a case of prevertebral abscess with Lemierre’s syndrome, which was difficult to differentiate from a retropharyngeal abscess and calcific tendinitis of the longus colli muscle.

A 49-year-old woman consulted her previous doctor with a one-month history of post-cervical pain. Brain MRI revealed no abnormalities and the patient was prescribed an analgesic. However, the symptoms worsened and the patient visited our emergency outpatient clinic. Based on the findings of CT and MRI, she was admitted to our department with a diagnosis of prevertebral abscess.

She was started on treatment with ceftriaxone and clindamycin, based on robust evidence of an inflammatory response in the blood tests, but her symptoms only continued to worsen. Later, she developed internal jugular vein thrombosis and bacteremia, which led to the diagnosis of Lemierre’s syndrome. A blood culture grew Streptococcus constellatus subsp. pharyngis and Parvimonas micra. Despite administration of tazobactam/piperacillin, the symptoms persisted, and the antibiotic was switched to meropenem. Thereafter, the symptoms gradually improved and resolved. A retrospective review of the case revealed that the Lemierre’s syndrome resulted from the prevertebral abscess rather than retropharyngeal abscess. The fact that interdisciplinary management involving the fields of otorhinolaryngology and orthopedics is required for the treatment of prevertebral abscess, retropharyngeal abscess, calcific tendinitis of the longus colli muscle, and infectious spondylitis, and that each disease involves areas in anatomically close proximity make it difficult to differentiate one from the other, and diagnosis and treatment are often delayed. In particular, all of these diseases, except calcific tendinitis of the longus colli muscle, require early diagnosis and early treatment since they could follow a serious course if treatment is delayed. In addition, Lemierre’s syndrome is usually caused by inflammation spreading from the pharynx; this was a rare case in which prevertebral abscess was the focus of infection.

Objective tinnitus that originates in muscles can be heard by others as well as by the patient. Although there have many reports of objective tinnitus, each report has been limited to a small number of cases that have varied from one another, with some being accompanied by such findings as voluntary and/or involuntary movement of the soft palate and eardrum as well as by blinking, and the etiology has remained unclear.

We analyzed 16 cases of objective tinnitus synchronous with the opening and closing of the eustachian tube. The voluntary and involuntary movements of the soft palate and eardrum, were consistent with the findings in previous reports. The 16 cases included 11 cases of patulous eustachian tube and in 10 of them the patient voluntary induced tinnitus in order to prevent the symptoms of a patulous eustachian tube. These patients created an opportunity to close the patulous eustachian tube by repeating opening and closing. The sound of the opening and closing of the eustachian tube became an objective tinnitus. The tinnitus was in 7 cases were heard only voluntary and in 9 cases were heard voluntary and involuntarily; one of patients was tentatively diagnosed with middle ear myoclonus and another was with pharyngolaryngeal myoclonus.

Patulous eustachian tube was first described as one of the causes of objective tinnitus. We speculated that the soft palate and eardrum movements were initially voluntary, but that some of them became involuntarily. If this involuntary movement is seen at the time of examination, it may be diagnosed as myoclonus. Psychological factors may be involved in the transitions from voluntary to involuntary, but further research will be necessary to assess this possibility.