Tonsillar focal diseases are defined as “diseases caused by organic and/or functional damage in organs distant from the tonsils, whose outcome is improved by tonsillectomy”. In 2023, a guideline for the clinical management of patients with tonsillar focal diseases was published by the Japan Society of Stomato-pharyngology. I would like to discuss the basis for the development of this guideline in this article.

Regenerative treatment for tympanic membrane (TM) perforation with Retympa^® (RT-TMP) began to be covered by the National Health Insurance program in Japan in November 2019. Although this novel treatment has obviated the need for elevating a meatal flap and harvesting graft material, the indication is limited to cases without a narrow external ear canal.

In this report, we present a case of TM perforation in a patient with external auditory canal stenosis. Because of the stenosis, we could initially not access the TM with the endoscope. Therefore, we enlarged the external bony canal by the endaural approach, which allowed us to access the TM perforation. Accordingly, we treated the perforation by RT-TMP. After the treatment, the perforation closed completely, and the patient reported hearing improvement.

In cases where the TM cannot be reached with the endoscope because of external auditory canal stenosis, enlargement of the external bony canal prior to RT-TMP could be a solution.

Rhinitis medicamentosa is a drug-induced, non-allergic rhinitis associated with long-term use of decongestant nasal sprays. The treatment is to discontinue the offending nasal spray, but this is sometimes difficult because of lack of patient cooperation. In the present study, we report two patients who were treated by surgery while still continuing to use the decongestant nasal spray. Case 1: 25-year-old male. He had been using tramazolin hydrochloride nasal spray for nasal obstruction for 11 years, but was referred to our department due to worsening nasal obstruction. We prescribed a nasal steroid spray and advised him to discontinue the decongestant nasal spray, but he did not discontinue the medication, complaining of insomnia upon any attempt to discontinue the spray. We decided to operate on the patient after explaining the possible risk of bleeding to him, because he also had nasal septal deviation and allergic rhinitis. Case 2: 22-year-old female. This patient had been receiving conservative treatment for nasal obstruction for 3 years, but she was referred to our department when her symptoms worsened. We diagnosed the patient as having chronic sinusitis and nasal septal deviation and decided to treat her surgically. At the time of the initial consultation, the patient denied using any nasal decongestant spray, but at admission, she was found to be using a combined tetrahydrozoline hydrochloride/prednisolone nasal spray. As in Case 1, we performed surgery after explaining the risk of bleeding to the patient. In both cases, profuse bleeding occurred immediately after mucosal incision and hemostasis was difficult to achieve with 5,000-fold bosmin. In both cases, however, the nasal obstruction improved and no nasal vasoconstrictors were needed. Surgical treatment for rhinitis medicamentosa should be avoided, if possible, given the risk of bleeding. Even in patients who deny using a decongestant nasal spray at the time of the initial history-taking, the possibility of rhinitis medicamentosa should be kept in mind.

Nasal vestibular carcinoma is often diagnosed several months after the onset of symptoms, because the manifestations in the early stages of the disease are often non-specific, with small ulcers and nonspecific symptoms such as nosebleeds and nasal obstruction.

The patient reported herein was an 81-year-old man who presented to us with the chief complaint of right nasal obstruction and a tumorous lesion with hemorrhage measuring approximately 10 mm in diameter in the right nasal vestibule. Biopsy results confirmed the diagnosis of nasal vestibular carcinoma. We performed excision of the right nasal vestibular carcinoma and reconstruction of the nasolabial groove with a skin flap under general anesthesia. Postoperative evaluation showed good skin valve grafting, improvement of the nasal obstruction, and no local recurrence. We made the diagnosis of a metastatic tumor in the nasal vestibule from gastric cancer, because the excised tumor showed similar histopathologic findings to those of the previously diagnosed gastric cancer in the patient. Postoperative systemic evaluation revealed that the tumor had also metastasized to the lung, and we initiated the patient on chemotherapy for systemic metastasis from gastric cancer.

When a nasal vestibular tumor is recognized and malignancy is suspected, early surgery is advisable, considering account the patient’s quality of life and wishes. Depending on the size of the tumor and depth of invasion, skin valvuloplasty should be considered, taking into account the cosmetic and functional aspects. In the present case, after removal of the right nasal vestibular tumor, we also performed a nasolabial sulcus valve reconstruction, with the patient showing a good postoperative course.

Nodular fasciitis, a commonly encountered condition in children and young adults, usually arises in the fascia, with reactive proliferation of myofibroblast-like cells in the surrounding subcutaneous tissue. It typically arises in the fascia and enlarges rapidly within weeks or months, usually less than 20 mm in size. Histopathology shows myofibroblast-like spindle-shaped cell proliferation. The condition often resolves spontaneously during follow-up, and recurrence post-resection is rare. In this report, we present two cases of nodular fasciitis. Case 1 was a 35-year-old male patient who had presented to his previous doctor a month earlier with swelling in the right cervical region, and was referred by the doctor to our hospital. We performed a thorough examination at our department; cervical ultrasonography revealed a well-defined, low-echoic mass measuring about 15 mm in diameter in the subcutaneous tissue. Imaging and aspiration cytology did not provide a definitive diagnosis. As the tumor did not show any spontaneous decrease in the size, the patient requested removal of the tumor, and we performed a right cervical tumor resection. Histopathological examination revealed findings suggestive of nodular fasciitis. Case 2 was a 49-year-old male patient who had presented to his previous doctor a month earlier with swelling of the right nasal dorsum, and was referred by the doctor to our hospital. Contrast-enhanced computed tomography revealed a mass with contrast effect measuring about 10 mm in diameter in the right cheek region. Imaging and aspiration cytology did not provide a definitive diagnosis. Because the tumor showed no spontaneous decrease in size, the patient requested removal of the tumor. We performed excision of the tumor under local anesthesia, and the histopathological diagnosis was nodular fasciitis. A definitive diagnosis of nodular fasciitis is difficult to obtain from physical and imaging examinations alone, and differentiation from malignant disease can be difficult. In order to avoid unnecessary extended resection, it is important to attempt to make an accurate diagnosis by imaging and cytology.

It is sometimes difficult to secure the airway in cases of head and neck cancer spreading to the mediastinum. We report 2 such cases in which we prevented airway obstruction by using an airway stent.

Case 1: A 58-year-old man with anaplastic thyroid carcinoma who presented with tracheal stenosis and dyspnea. As the patient was judged as being inoperable, we started him on treatment with lenvatinib. However, since the tumor continued to grow, causing extramural tracheal narrowing, we inserted a hybrid-type airway stent to prevent airway obstruction. The patient needed airway stenting on two occasions subsequently, but he died of MRSA pneumonia 9 months after the diagnosis. Case 2: A 69-year-old man developed cancer of the neck and mediastinum of indeterminate site of origin with tracheal stenosis. The histology was squamous cell carcinoma. As the tumor continued to grow causing airway stenosis, we inserted a hybrid-type stent. The patient’s dyspnea improved and we started him on 6-course chemotherapy with cisplatin + fluorouracil + pembrolizumab. The airway stent slipped out 2 months after it was inserted because of tumor reduction. Treatment with pembrolizumab was continued and the tumor showed no further increase in size.

Airway stenting has been performed for tracheal stenosis complicating lung cancer and esophageal cancer. Airway stenting in some cases of thyroid cancer has also been reported, although in a palliative setting, as in Case 1. However, with the development in recent years of new treatments, such as immune checkpoint inhibitors and molecular-targeted agents, airway stenting has been used as a part of aggressive treatment in patients with head and neck cancer.

The field of view and working space in the parapharyngeal space are limited for surgical manipulation. However, many important blood vessels and nerves run through this area, and surgery should be performed under clear vision to ensure safety. In the past, inter-capsular resection of schwannomas in the parapharyngeal space was performed blindly and manually because it was difficult to dissect the head side of the tumor under clear vision. To resolve this problem, we devised a continuous aspiration syringe method and examined the status of traction and aspiration, presence/absence of capsular damage due to aspiration and traction, and the possibility of detaching the tumor to the head side under clear vision using this method in four cases. The nerve of origin was the sympathetic chain in 3 cases and the vagus nerve in 1 case, the operating time was 171–265 minutes, and the volume of blood loss was 23–44 ml. The results suggest that the continuous aspiration syringe method may be useful for the resection of schwannomas arising in the parapharyngeal space, as it allows dissection of the undissected portion of the tumor under clear vision by traction through the parapharyngeal space while continuously aspirating the tumor in the tumor capsule.

Parathyroid gland hemorrhage is known as one of the causes of spontaneous deep neck hematoma. We encountered a case of deep neck hematoma caused by hemorrhage from a parathyroid adenoma and report the case with some bibliographic consideration.

A 59-year-old woman presented to our hospital with a 3-day history of sore throat and left cervical swelling. Physical examination revealed a subcutaneous hematoma in the anterior cervical region and laryngoscopy revealed a submucosal hematoma in the pharynx. Computed tomography revealed a deep neck hematoma extending from the anterior neck to the thyroid area and a mass on the left dorsal aspect of the thyroid. Because laboratory examination also revealed hypercalcemia and an increased serum level of intact PTH, we suspected a parathyroid adenoma as the source of bleeding. A few days later, the symptoms and clinical findings improved spontaneously without surgery. Findings of MIBI scintigraphy and other medical examinations suggested that the deep neck hematoma was probably caused by rupture of the parathyroid adenoma. Therefore, about 2 months after the patient’s initial visit, we performed surgery to remove the parathyroid adenoma that was suspected as the source of bleeding.

The possibility of extracapsular parathyroid hemorrhage should be born in mind in patients presenting with acute non-traumatic neck swelling. Findings of contrast-enhanced computed tomography and an increased serum intact PTH level could aid in the diagnosis of parathyroid gland hemorrhage. While parathyroid hemorrhage may lead to airway obstruction, patients with parathyroid hemorrhage in whom the risk of airway obstruction is low could be followed up without surgery.

In transcanal endoscopic ear surgery (TEES), bone removal may be needed, for example, in cholesteatoma cases. To maintain visibility without having to use costly tools, some use a needle in the ear canal to infuse saline, while a pouch prevents excess fluid from leaking out. This method makes underwater surgery feasible and cost-effective.

Inflammatory bowel disease (IBD) is an autoimmune disease that is often accompanied by extraintestinal manifestations such as arthritis, but reports of hearing loss as an extraintestinal manifestation of IBD are rare. In this study, we investigated the clinical features of sensorineural hearing loss associated with IBD.

Patients with IBD and hearing loss who were registered between October 2005 and September 2022, in whom the diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD) had been confirmed by gastroenterologists, and the hearing loss had been diagnosed as sensorineural hearing loss of unknown cause by otolaryngologists were included in this study.

The study subjects were 32 patients (including nine female patients, 18 cases of UC, and 14 cases of CD) aged between 10 and 78 years old. Hearing loss associated with IBD was more common in males, and the median age at onset of hearing loss associated with UC was 56 years, while that associated with CD was 33 years. Two patients reported hearing loss preceding the onset of IBD on both sides, while 38 ears in 30 cases developed hearing loss after the onset of IBD. The hearing types varied among the 42 ears. Hearing loss developed within 10 years of the diagnosis of IBD in about 63% of cases, with a median interval of 9 years from the diagnosis of IBD in the 32 cases.

In some cases, it was suspected that azathioprine and infliximab, both of which are therapeutic agents used for IBD, might have contributed to the hearing loss. However, other IBD medications were not suspected as having contributed to the hearing loss in any of the patients.

The pathogenesis of hearing loss associated with IBD is still unknown, and clarification of the relationship between IBD and sensorineural hearing loss, and also the underlying pathophysiology through large-scale investigations is awaited.