I explain the key points of DISE and surgery regarding hypoglossal nerve electrical stimulation therapy. DISE should not be performed with excessive sedation, and oxygen should be avoided as much as possible. For surgery, the first step in the cervical region is to identify the digastric muscle. The key to smooth identification is to identify the anterior border of the submandibular gland. The key points in the main trunk of the hypoglossal nerve are the determination on the presence or absence of Type 2 (HG late) and separation of the HG late from the main trunk of the hypoglossal nerve. In the thoracic region, if the fatty layer under the pectoralis major muscle is found, never perform rough manipulation, and if the muscular layers of the external and internal intercostal muscles are not found, probe more medially. As of June 2024, there have been only 38 cases of this HNS surgery in Japan. This is despite the fact that there are 100,000 to 150,000 patients in Japan who are intolerant to or unable to tolerate CPAP. This surgery offers the fulfillment surgical techniques that cannot be experienced in other otorhinolaryngological surgeries, such as intra-nerve manipulation and intra-thoracic surgery. I eagerly hope that many otorhinolaryngologists will participate in treatment that includes this surgery.

Regenerative treatment for tympanic membrane perforation using Retympa^® is a simple, minimally invasive treatment method that yields stable therapeutic outcomes, and is considered suitable for use in clinics. Herein, we report on cases treated at a clinic. The subjects were 38 patients and 40 ears treated at this clinic between July 2020 and November 2022. The patients ranged in age from 10 to 90 years old, with a mean age of 63.4 years, and included 14 male and 24 female patients. The most common etiology was chronic perforated otitis media, followed by post-placement of a tympanostomy tube. The perforations ranged in size from small to medium to large, in that order. The perforation closure rate with the first treatment with Retympa^® was 67.5% (or 77.5% when cases that showed a marked reduction in size, but not complete closure, of the perforation were included). The closure rate with the first treatment was 71%, 78%, and 34% for small, medium, and large perforations, respectively. In this study, our investigation included cases that received treatment for both ears simultaneously, cases of post-operative perforation, cases with good hearing, and refractory cases. Retympa^® is considered as an effective treatment modality that yields stable outcomes even in clinics.

Idiopathic CSF otorrhea is a relatively rare condition. The major site of leakage is the canopy of the tympanum and mastoid cavity, and the condition is often associated with idiopathic intracranial hypertension. A 62-year-old man presented with a 1-year history of left otorrhea. He was treated for exudative otitis media, but continued to have pulsatile serous otorrhea. He was referred to our hospital with suspected CSF otorrhea. Imaging showed a bone defect behind the lateral semicircular canal ridge, and we performed transmastoid closure. Using a combination of microscopy and endoscopy, we identified the fistula in the bony defect and dura and closed it with fascia, bone fragments, and a peroneal temporal muscle valve. A more detailed imaging study showed a bone defect in the same part of contralateral side, suggesting meningeal varus in a congenital bone defect; MRI showed an empty sella, and MR venography showed obstruction of the right transverse sinus. However, ophthalmologic examination did not reveal any papillary edema, and there was no evidence of increased CSF pressure at the time of surgery. As it was possible that intracranial pressure was regulated by the CSF otorrhea, we considered that there was a risk of increased CSF pressure with fistula closure. The patient will be followed up with special attention paid to visual symptoms and headache.

Congenital anosmia is a rare condition, and some individuals may not even consider consulting an otolaryngologist.

We encountered two cases of congenital anosmia, with both individuals reportedly lacked the sense of smell since birth. Both were referred to our clinic by a local otolaryngologist for further evaluation of the anosmia. The mother of one was curious about the lack of a sence of smell in her child, which led her to seek an otolaryngologist consultation. Neither patient had any significant past medical history. Standard olfactory tests revealed no significant findings in either case. There were no abnormal nasal findings either of the patients. Head MRI revealed aplasia in the olfactory bulb and olfactory sulcus, leading to a diagnosis of congenital olfactory dysfunction in both patients. Blood test results confirmed the absence of gonadal insufficiency.

Herein, we summarize the clinical and imaging characteristics of reported cases, to date, in Japan of congenital anosmia. It is important for otolaryngologists to be aware that this condition could be associated with hypogonadism and such diseases as Kallmann syndrome, which require prompt treatment.

We report a case of nodular fasciitis in the lacrimal sac. The patient was a 30-year-old man who was referred to our department with the complaints of increased lachrymation and swelling of the medial wall of the right orbit. A biopsy was performed under local anesthesia, and the histopathological findings led to the suspicion of nodular fasciitis. In collaboration with an ophthalmologist, the lesion was resected using an external nasal incision and a transnasal endoscopic approach with a navigation system under general anesthesia. The lesion was completely removed with preservation of the external ocular muscle. Postoperative histopathology revealed that the lesion was indeed nodular fasciitis. Currently, neither obvious postoperative nasolacrimal duct obstruction, nor disturbance of the optical functions is observed. There is also no evidence of either a residual or recurrent lesion.

Nodular fasciitis has frequently been reported in the buccal area of the head and neck region, but it should be borne in mind that it can also occur in intraorbital lesions.

Mammary analogue secretory carcinoma (MASC) is a malignant salivary gland tumor that was first described by Skálová et al. in 2010. Before that MASC was histologically misclassified as acinic cell carcinoma, adenocarcinoma not otherwise specified, or cystadenocarcinoma. Herein, we report the case of a 47-year-old man with MASC of the left salivary gland. The patient was initially diagnosed, by preoperative fine needle aspiration cytology, as a case of acinic cell carcinoma; however, postoperative histopathology and immunohistochemistry revealed that the diagnosis of MASC.

The carcinoma was further diagnosed as an intermediate-grade salivary gland carcinoma, and the patient received radiotherapy as additional postoperative treatment. Following this treatment, no recurrence or metastasis was detected until the last follow-up. MASK is known to carry genetic translocation, the NTRK mutation. Selective targeting of this mutation could be the ideal way to treat this cancer.

In patients with coagulopathies such as hemophilia who undergo surgical procedures, coagulation factor supplementation during the perioperative period is crucial. Herein, we report the case of a patient with a history of hemophilia A who underwent bilateral tonsillectomy, septoplasty, and submucous turbinectomy.

The patient, a 40-year-old male, presented to us with purulent nasal discharge, nasal obstruction, pharyngeal pain, and snoring. We diagnosed the patient as having chronic tonsillitis and deflected nasal septum, and performed bilateral tonsillectomy, septoplasty, and submucous turbinectomy. We collaborated with a hematologist specialized in blood disorders to ensure that the patient received Factor VIII supplementation during the perioperative period.

Transient bleeding was observed post-tonsillectomy after the completion of Factor VIII supplementation, however, hamostasis was achieved by additional administration of Factor VIII. Factor VIII supplementation was also undertaken during the septoplasty and submucous turbinectomy procedures, without postoperative bleeding.

All of tonsillectomy, septoplasty, and submucous turbinectomy carry a high risk of bleeding. Therefore, when performing these surgeries on patients with coagulation abnormalities, collaboration with a hematologist specialized in blood disorders for perioperative bleeding control is essential.

Montgomery T-tubes are used for treating of subglottic or tracheal stenosis. Products marketed by Koken Co., Ltd. in Japan are easy to use in such patients. Due to the structure of the T-tube, however, positive pressure ventilation via the T-tube while maintaining safe anesthesia and ventilation is difficult.

We report the case of a 59-year old woman who presented to us with stridor, in whom we performed tracheostomy. The patient was clinically diagnosed as having idiopathic subglottic stenosis. Her stenotic scar was removed via an external tracheal incision and a T-tube was placed under general anesthesia. Positive pressure ventilation was continued by placement of “a RAE (Ring-Adair-Elwyn) tube within the T-tube”.

We used a T-tube (inner diameter of the side arm 9 mm and the main arm 10 mm/outer diameter 12 mm) manufactured by Koken Co., Ltd. and a Shiley oral RAE tracheal tube with a TaperGuard cuff (inner diameter 5.5 mm/outer diameter 7.6 mm) manufactured by Covidien Japan Co., Ltd. We conclude that treatment of idiopathic subglottic stenosis under general anesthesia by placement of “a RAE tube within a T-tube” is safe if it is possible to obtain tubes of suitable sizes.

Preserving the parathyroid glands during thyroid surgery is important to prevent postoperative hypoparathyroidism. However, it is not easy to identify the parathyroid glands intraoperatively by naked-eye visual examination. Recently, autofluorescence of the parathyroid glands in the near-infrared region has been discovered. Herein, we report a case of total thyroidectomy performed using the exoscope ORBEYE^®, in which the parathyroid glands were identified in the infrared observation mode and preserved. A 45-year-old woman was referred to our hospital with anterior neck swelling. Ultrasonography revealed two masses in the right lobe of the thyroid gland, with partial calcification. A 30-mm mass was found at the lower pole of the left lobe of the thyroid gland. Considering the possibility of malignancy, total thyroidectomy was performed. ORBEYE^® was used to perform vascular treatment and ensure nerve preservation around the thyroid gland, and the parathyroid glands were identified in the infrared observation mode and preserved. Postoperatively, the parathyroid function was preserved. Since this is the first report of the use of ORBEYE^® as an infrared device for identifying the parathyroid glands, it is necessary to accumulate further cases and examine the usefulness of this method in the future.

Japan is considered as being among the countries with the highest daily consumption of iodine. Iodine-induced hypothyroidism can be caused by prolonged high intake of seaweeds such as root kelp for many years, and we report three patients with hypothyroidism caused by excessive iodine intake diagnosed in an outpatient otorhinolaryngology clinic, in whom normal thyroid function was restored by iodine restriction.

All the three patients were male, in their 40 s, 60 s, and 80 s, and while two patients did not show any clinical symptoms or signs of hypothyroidism, the third complained of leg edema. All were referred to the otorhinolaryngology department because of an enlarged thyroid gland and were found to have well-defined thyroid nodules on ultrasonography. All patients were hypothyroid with elevated serum TSH and decreased serum FT4 levels. The test for thyroid peroxidase antibodies was negative in all three patients. A careful clinical history revealed that all patients had a history of excessive iodine consumption in the form of seaweed, mainly root kelp.

We diagnosed the patients as having iodine-induced hypothyroidism and instructed them to limit their iodine intake, and the thyroid function in each of the patients improved within approximately 3 months.

The cause of iodine-induced hypothyroidism can often be determined by detailed history taking.

Malignant neoplasm arising in a preexisting spiradenocylindroma is an extremely rare malignant cutaneous adnexal tumor. Once malignant transformation occurs in pre-existing spiradenomas, cylindromas, or spiradenocylindromas, the lesions begin to grow rapidly. Since the efficacy of irradiation and chemotherapy has not yet been established, complete resection with a safety margin is required for a positive treatment outcome. When complete resection proves impossible, local recurrence and/or distant metastasis can be expected in the short term, resulting in a poor prognosis. We encountered a case of malignant neoplasm arising in a spiradenocylindroma in the neck region.

An 84-year-old man with severe dementia was referred to our department because of sudden and rapid enlargement of a neck mass over the previous 2 months and a deteriorating quality of life (QOL). Findings of fine needle aspiration cytology suggested an epithelial tumor (class III). CT revealed a huge tumor measuring 80 × 90 × 110 mm in size showing heterogenous enhancement in the right neck region. The tumor did not invade deeper structures. No cervical lymph node metastases or distant metastases in the thoracoabdominal region were observed. The tumor was completely resected with a safety margin of 10 mm under general anesthesia for the purpose of definitive diagnosis and improving the QOL of the patient. The postoperative wound was closed after local treatment and irrigation for one month, and the QOL of the patient improved. On postoperative histopathology, the resected specimen was definitively diagnosed as a malignant neoplasm arising in a spiradenocylindroma, based on the finding of coexistence of a spiradenoma and cylindroma with multiple mitoses. No recurrence has been observed until now, 12 months since the surgery. However, We believe that continued regular follow-up of the patient is still needed.

In otorhinolaryngological practice, extrapulmonary tuberculosis with lesions in the cervical lymph nodes, pharynx, or middle ear is not uncommon, although it is sometimes difficult to diagnose. In this study, we examined the clinical features of cervical tuberculous lymphadenitis and the diagnostic approach.

We reviewed the data of 18 cases of cervical tuberculous lymphadenitis that were diagnosed at our department between 2011 and 2021.

The patients ranged in age from 22 to 87 years old (mean 47.3 years old). There were 10 men and 8 women; 10 were Japanese and 8 were foreign nationals. Fine needle aspiration cytology was performed in 13 cases, and the positivity rate for tuberculosis was 18.8% on cytology, 46.2% on the smear test for Mycobacterium tuberculosis, 46.2% on culture, and 76.9% on the PCR test. The positivity rate on any one of all the tests was 92.3% (12/13 cases), suggesting that the positivity rate increased when a combination of tests was used. Open biopsy was performed in the remaining 4 cases, and the diagnosis was confirmed in 3 of the 4 cases.

The remaining 3 cases were judged comprehensively by interferon-gamma release assays (IGRA) and other methods.

The most common subjects in this study were young foreign nationals from areas with a high prevalence of tuberculosis and elderly Japanese patients with underlying diseases such as diabetes mellitus or undergoing dialysis. There were cases in which tuberculosis was not suspected at the time of the initial examination, so that countermeasures to prevent exposure to tuberculosis were not taken during the examination. We consider that combined use of multiple testing methods on specimen obtained by fine needle aspiration increases the diagnosis rate and allows unnecessary open biopsy to be avoided.

When cervical lymphadenopathy is detected, it is important to keep the possibility of cervical tuberculous lymphadenitis in mind, and in high-risk cases, various tests should be performed to exclude tuberculosis.