Based on recent research on vestibular migraine (VM), we describe the characteristics, diagnosis, and treatment of VM, and also the disorders commonly associated with this condition. While the concept of VM has come to be known worldwide since the International Classification of Headache disorders (ICHD) defined the diagnostic criteria for VM in 2012, VM is still often not accurately diagnosed. Headache is the fourth most strong physical symptom in patients with chronic vertigo, and the type and duration of vertigo vary greatly in patients with VM. The Dizziness and Headache Diary is a useful tool for correct diagnosis of vertigo. It may be difficult to differentiate VM from Ménière’s disease (MD) as their clinical features are very similar. Vestibular function tests such as vestibular evoked muscle potentials (VEMP) and video head impulse test (V-HIT) could be useful to differentiate between these two conditions. VM is also seen in children and is now defined as vestibular migraine of childhood (VMC). It is one of the most common equilibrium disorders diagnosed in children.

Introduction: While diagnostic criteria for vestibular migraine have been developed, no treatment has been established for dizziness with headache. In attempting to establish an effective treatment for dizziness with headache, we reviewed the data of patients with dizziness and headache who had been prescribed the Kampo medicines gosyuyuto and ryokeijyutsukanto at our hospital.

Methods: We retrospectively reviewed the medical records of patients with headache and dizziness who had visited our department between April 2018 to March 2022 and were treated with gosyuyuto and ryokeijyutsukanto.

Results: A total of 22 patients were included in the study, including 6 (27%) patients with vestibular migraine, 6 (27%) patients with Meniere’s disease, 5 (23%) patients with vertigo, 2 (9%) patients with persistent postural-perceptual dizziness, 1 (5%) patients with dizziness after sudden hearing loss, 1 (5%) patient with psychogenic dizziness, and 1 (5%) patient with unilateral semicircular canal paralysis. The efficacies of gosyuyuto and ryokeijyutsukanto were classified as follows: dizziness; improved, slightly improved, and unchanged dizziness in 13 (59%), 2 (9%), and 7 (32%) patients, respectively, headache; improved, slightly improved, and unchanged in 15 (68%), 1 (5%), and 6 (27%) patients, respectively. Both dizziness and headache improved in 13 (59%) patients, both dizziness and headache slightly improved in 1 (5%) patient, headache improved in 2 (9%) patients, and neither dizziness nor headache improved in 5 (22%) patients. Both dizziness and headache improved in all 6 patients with vestibular migraine.

Conclusion: The combination of gosyuyuto and ryokeijyutsukanto was effective in all cases of vestibular migraine and some cases of dizziness with headache associated with other conditions. Given the lack of a well-established treatment for this type of dizziness, Kampo medicine can also be used to treat dizziness with headache associated with conditions other than vestibular migraine.

We report a case of tuberculous otitis media. This disease is very rare and hence not easily diagnosed by most otolaryngologists in Japan. An 86-year-old man with hearing loss and ear discharge was referred to Kariya Toyota General Hospital. Initially, he was diagnosed as having acute otitis media at a local clinic, and treated with antibiotics and myringotomy, but his symptoms failed to improve. At his first visit to our hospital, we diagnosed him as having otitis media with effusion and inserted a tympanostomy tube. However, 32 days later, his ear discharge persisted. We then suspected intractable otitis media and conducted tests to rule out tuberculous otitis media and anti-neutrophil cytoplasmic antibody (ANCA)-associated disease; the results led to the diagnosis of tuberculous otitis media. The interval from a patient’s first visit to a medical institution to diagnosis of the disease is called “Doctor’s delay.” On the other hand, the interval between the onset of symptoms and the patient’s first visit to a medical institution is called “Patient’s delay.” In this case, the Doctor’s delay was 11 weeks, while the Patient’s delay was only a few days. It is often difficult to diagnose tuberculous otitis media in the absence of typical physical findings. A delay in diagnosis may lead to the development of pulmonary tuberculosis, since patients with tuberculous otitis media also often suffer from pulmonary tuberculosis. Hence, in patients presenting with intractable otitis media, examinations such as smear and culture examinations and polymerase chain reaction assay of ear discharge fluid and biopsy of granulation tissue should be conducted to rule out tuberculosis otitis media.

Otogenic intracranial complications can become severe and life-threatening, although the incidence of these complications has decreased because of the wide use of antibacterial drugs and advances in imaging techniques. We encountered three cases of brain abscess caused by middle ear cholesteatoma.

Case 1: A 74-year-old male who presented with otorrhea, headache, neck pain, and fever. Physical examination revealed impaired consciousness and nuchal rigidity. We diagnosed the patient as having brain abscess due to middle ear cholesteatoma. First, we only performed drainage of the brain abscess, but the abscess re-grew. Therefore, we performed abscess drainage and radical mastoidectomy simultaneously with the department of neurosurgery. Case 2: A 52-year-old male who presented with fever and headache. We diagnosed the patient as having a brain abscess of unknown cause, and the abscess improved with drainage. Subsequently, We found that the abscess was caused by a middle ear cholesteatoma and performed tympanomastoidectomy. Case 3: A 55-year-old male who presented with earache and headache. We diagnosed the patient as having a brain abscess due to a middle ear cholesteatoma. From the beginning, the treatment was planned as a joint operation with the department of neurosurgery, and abscess drainage and tympanomastoidectomy were performed simultaneously.

Although in all cases, abscess drainage and ear surgery were performed, cure was achieved in all cases, with no residual neurological sequelae. The timing of abscess drainage and ear surgery varies from case to case. Treatment of otogenic brain abscess requires intervention for both the brain abscess and middle ear lesion. However, the order in which the two should be treated has not been established yet. The treatment strategy should be decided based on the presence/absence and severity of neurological symptoms in each case and the medical care system of the facility. Close collaboration with the department of neurosurgery may be particularly important.

Juvenile angiofibroma is a benign tumor that predominantly affects adolescent males and invasively destroys the nasal sinuses and pterygopalatine fossa. The treatment of first choice is surgery, but there is a risk of recurrence due to intraoperative hemorrhage and difficulty in securing an adequate field of vision because of the location of the tumor in the posterior nasal cavity. In this study, we report a case in which a Radkowski stage IA tumor was removed endoscopically by segmental resection. The patient was a 21-year-old male with a hemorrhagic tumor in the left posterior nasal cavity. Computed tomography and magnetic resonance imaging showed a markedly enhancing tumor measuring approximately 35 mm in diameter that obstructed the left posterior nasal cavity and nasopharynx. Preoperative embolization was performed the day before the surgery to reduce the tumor vascularity. Intraoperatively, the tumor was segmentally resected using a LigaSure^TM Maryland to improve visualization for surgical removal. The segmental resection allowed clear visualization of the base and complete removal of the tumor. Intraoperative bleeding was minimal and there was no postoperative recurrence. We believe that segmental resection is effective for patients in which it is difficult to secure an adequate visual field, even if the tumor is localized in the nasal cavity.

Nevoid basal cell carcinoma syndrome (NBCCS) is a rare disease that was first reported by Gorlin in 1960. It is autosomal dominant disorder characterized by early appearance of multiple basal cell carcinomas (BCCs), odontogenic keratocysts of the jaw, ectopic calcifications, palmar and plantar pits, and anomalies of the ocular, skeletal, and reproductive systems. Herein, we report a patient who was definitively diagnosed as having NBCCS, in whom the odontogenic keratocysts were removed by endoscopic endonasal surgery (EES).

A 10-year-old boy was referred to our department for the treatment of a gradually enlarging odontogenic keratocyst of the left maxilla. CT and MRI examinations showed multiple cystic lesions in the maxilla and mandible. We performed EES on the left maxilla in consideration of the need to preserve the postoperative function. The keratocyst in the maxillary sinus was removed completely by EES, and the oral surgeon removed the residual lesion in the left maxillary bone from the oral cavity. However, the post-procedure histopathology failed to reveal any keratocyst in the lesion removed from the left maxillary bone. The histopathological findings of the maxillary sinus lesion suggested a high risk of recurrence of the keratocyst. However, the postoperative course was favorable, with no recurrence of the keratocyst detected for 2 years after its removal.

Genetic testing is useful for confirming the diagnosis of NBCCS and predicting the prognosis of this condition. Since no genetic testing was performed in this case, repetitive imaging tests would be needed for a long period of time to detect not only recurrence but also new lesions. Total excision of an odontogenic keratocyst may be desirable because of the risk of development of carcinoma. EES may be useful for the treatment of keratocysts to prevent deterioration of the quality of life of the patient.

Background: Isolated sphenoid sinus diseases are relatively rare, and various approaches to treating diseases limited to the sphenoid sinus have been repoted. We examined the usefulness and limitations of sphenoid sinus opening via the endoscopic transnasal transseptal approach employed at our department.

Subjects: Fifteen cases of isolated sphenoid sinus diseases managed by sphenoid sinus opening via the endoscopic transnasal transseptal approach among 982 endoscopic surgeries performed at our department between April 2012 and December 2020 were included in this study.

Results: The diseases comprised 7 cases of papilloma, 4 cases of fungal sphenoid sinusitis, 2 cases of bacterial sphenoid sinusitis, and 2 cases of sphenoid sinus cysts. There were 11 cases of initial surgeries and 4 cases of revision surgeries. The diseases that needed revision surgeries included 3 cases of papilloma, 1 case of bacterial sphenoid sinusitis, and 1 case of sphenoid sinus cyst. The postoperative observation period ranged from 25 to 2964 days (median, 370 days). Except for one case, the postoperative course was favorable, with no recurrence observed in any of the patients until date.

Conclusion: This endoscopic transnasal transseptal approach is considered as being useful for widely opening the sphenoid sinus for treating fungal infections and papillomas. Isolated sphenoid sinus lesions are rare and given the presence of important organs around the sinus, preparation for complications is crucial before surgery.

Fixed drug eruptions are characterized by the repeated development of round or oval erythematous lesions and edematous changes at the same site after administration of the causative drug. Localized redness, irritation, burning, and itching occur after 30 minutes to several hours of oral administration of the causative drug. In severe cases, the eruptions progress to Stevens-Johnson syndrome and toxic epidermal necrolysis, which are potentially life-threatening. Common sites are the skin on the hands and feet, and mucocutaneous junctions such as the lips and vulva. Since mucosal lesions, such as in the buccal or pharyngeal mucosa, sometimes occur, it is necessary to differentiate the condition from infectious diseases, inflammatory diseases, autoimmune diseases, etc.

We encountered two strongly suspected cases of fixed drug eruption with lesions confined to the oral cavity. Both cases showed a relatively rapid course, with erythematous lesions accompanied by swelling and pain observed on the lips and oral mucosa. There were no lesions at any other sites and no history of similar symptoms in either case. A dermatologist suspected fixed drug eruption in both cases, even though fixed drug eruptions associated with lesions only on the lips and oral mucosa are relatively rare. However, it is also difficult to make a definitive diagnosis of fixed drug eruption in patients presenting with only mucosal lesions. Fixed drug eruption may progress to SJS or TEN if ingestion of the causative drug is continued. Therefore, it is important to recognize the possibility of drug eruption at an early stage and make an early diagnosis/administer prompt and appropriate treatment in cooperation with a dermatologist.

Cationic surfactants are used as disinfectants, and have strong protein coagulation effects that directly cause skin and mucous membrane disorders. Didecyldimethylammonium chloride (DDAC) is a cationic surfactant that is used in the livestock industry. In patients presenting with mucosal damage to the pharynx and larynx caused by accidental ingestion of a cationic surfactant, it is important to bear in mind the risk of development of airway stenosis; several such cases requiring tracheostomy have been reported.

Herein, we describe a case in which a patient presented to us about a day after accidental ingestion of a disinfectant containing DDAC as its main ingredient and recovered after receiving conservative treatment. The patient was a 67-year-old woman who was working part-time at a chicken farm. She mistook disinfectant stored in the refrigerator for water and began to drink it. But after swallowing a small amount, she realized her mistake, spat the rest of the liquid out, then gargled with water. Three hours later, she developed a sore throat. The pain worsened, making oral intake difficult the following day. She visited our hospital approximately 20 hours after the accidental ingestion. The mucous membranes of the oral cavity and laryngopharynx showed whitish discoloration, and edematous swelling was observed in the bilateral arytenoid regions; however, the airway was intact. We determined that the disease was treatable conservatively and started the patient on a steroid and antibiotics. Three hours after the initial steroid administration, laryngoscopy revealed improvement of the arytenoid swelling. The mucosal lesions and sore throat improved over time, and the patient was discharged on the 8th day of hospitalization.

We considered tracheostomy in the present case, but considering the time that had passed since the accidental ingestion, we decided on conservative treatment. The steroid treatment proved effective for the laryngeal edematous swelling, and the patient’s condition improved without tracheostomy.

Laryngeal tuberculosis is a rare condition that could mimic laryngeal carcinoma. We report the case of a 54-year-old female patient with breast cancer, in whom 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) revealed hypermetabolic foci in the larynx and a right cervical lymph node. We initially suspected laryngeal tumor, but histological examination of a laryngeal biopsy specimen revealed necrotizing granulomatous inflammation. Mycobacterium tuberculosis was detected by bacterial culture of a laryngeal biopsy specimen and by transcription-reverse transcription concerted reaction (TRC) assay of a lymph node biopsy specimen, which led us to make the definitive diagnosis of laryngeal and cervical lymph node tuberculosis. The patient was started on anti-tuberculosis therapy and showed a good response to the treatment within 6 months. This case serves to underscore the fact that the possibility of tuberculosis should be borne in mind in the differential diagnosis of laryngeal tumors.

Autonomously functioning thyroid nodule (AFTN) is a condition where the thyroid nodules autonomously secretes thyroid hormone in a TSH-independent manner. In the present study, we reviewed the data of 13 patients with AFTN; the patients comprised 3 male and 10 female patients with a mean age of 62.6 ± 18.5 years (age range, 33–86 years) who had undergone surgery at the study center between 2012 and 2021; we collected data on the tumor volume, preoperative and postoperative serum FT3, FT4, and TSH levels, reason for consultation, and postoperative complications. The most common reasons for consultation were symptoms of thyrotoxicosis, such as tachycardia and atrial fibrillation, and presence of a cervical mass. A significant correlation was found between the volume of the functional nodules and the preoperative serum FT3 and FT4 levels, which were above the reference values in all the patients. The serum FT3 and FT4 levels decreased quickly to their respective normal ranges in all the patients following resection of the nodules, and those who were taking antithyroid medications were able to stop the medications from postoperative day 1. Although malignant transformation of AFTNs is considered rare, the finding of papillary carcinoma on postoperative histopathology in one case suggests the importance of always bearing in mind the possibility of malignancy when examining functional nodules, similar to the case with other types of nodules.

Other treatment options for AFTNs include medical therapy and ablation therapy, but these generally require prolonged treatment over several months to years. In the present case series, we found no cases of recurrent laryngeal nerve palsy, one of the potential complications of surgery. Surgery is indicated in patients who can tolerate the surgery, because it offers a rapid therapeutic effect and the opportunity to make a histopathological diagnosis.