Otologic lateral skull base surgery includes all surgical approaches that are employed for epidural lesions of the temporal bone and the lateral skull base. Typical surgical procedures include Subtotal Petrosectomy, Transotic Approach, Infratemporal Fossa Approach: ITFA Type A, B, C, (D), and among others, Transtemporal Supralabyrinthine Approach (modified Middle Cranial Fossa Approach), Translabyrinthine Approach, Petrosectomy, Extended Petrosectomy, etc. These procedures are often combined as appropriate for treatment. Typical target diseases include petrous bone cholesteatoma, paraganglioma (glomus temporale tumor), and acoustic schwannoma (vestibular schwannoma), Additional indications include intractable chronic suppurative otitis media, otologic CSF leakage, Gradenigo syndrome, and special cases of cochlear implant surgery.
The following three points about these types of surgeries are described in this review. 1) The concept of subtotal petrosectomy and ITFA Type A, B surgery, which are the basic surgical procedures for otologic lateral skull base surgery. 2) The diagnosis and management of petrous bone cholesteatoma, cholesterin granuloma (cyst), and other benign tumors. 3) Application of lateral skull base surgery specifically to cochlear implant surgery.
Objectives: In Hiroshima Prefecture, the forest area of Japanese cypress outnumbers that of Japanese cedar by about twofold. In contrast to the case of cedar pollen, the amount of cypress pollen dispersion has been shown to increase over the years. We, therefore, investigated whether the changes in pollen dispersion amount and period had any effects on the degree of antigen sensitization against cedar and cypress pollens in allergic rhinitis patients.
Methods: We retrospectively surveyed the data of 8,558 patients who had allergy blood tests at Hiroshima University Hospital from 2001 to 2018. Antigen-specific IgE levels for cedar and cypress were determined by ImmunoCAPTM Specific IgE systems. The pollen dispersion was annually monitored by a gravitational pollen sampler from 1996 to 2018. The cypress and cedar pollen counts were determined by staining with Calberla solution.
Results: An increase in both the amounts and dispersion periods of Japanese cypress pollen, as compared to that of cedar pollen, tended to be observed in Hiroshima Prefecture. The proportion of patients with positive ImmunoCAP scores increased for both cedar and cypress. However, the rate of increase was up to 25% for cypress as compared to 5% for cedar. Analysis by age group indicated that the rate of increase in cypress sensitization was the most significant in the younger population of patients aged less than 40 years old.
Conclusions: In Hiroshima Prefecture, the degree of antigen sensitization to Japanese cypress has risen due to an increase in both the number and period of pollen dispersion. Furthermore, the CAP score for cedar still remained positive in these sensitized patients. We consider that they are likely to suffer from continuous exposure to antigens in amounts in sufficient to maintain cedar sensitization.
We report the case of a patient with traumatic pseudoaneurysm, who developed massive bleeding during endoscopic sinsu surgery.
A 23-year-old drunk man sustained severe injuries when he fell from the second floor of his home and was transported to the hospital emergency department. He was diagnosed as having traumatic subarachnoid hemorrhage, brain contusion, skull base fracture, pneumoencephalopathy, maxillary fracture, right distal radius fracture, and admitted to the hospital. He was transferred to our oral surgery department for maxillary fixation to treat the maxillary fractures. Cerebrospinal fluid rhinorrhea was suspected due to a skull base fracture, and the patient was referred to the otorhinolaryngology department. Since there was no obvious cerebrospinal fluid leakage, the patient was followed up. However, as the rhinorrhea persisted, endoscopic sinus surgery was performed under general anesthesia to confirm and treat cerebrospinal fluid leakage. The sphenoid sinuses of both sides were filled with clot-like masses with strong pulsations. Hematomas were suspected, but when a piece of tissue was removed from the left sphenoid sinus mass, arterial bleeding occurred. Hemostasis was accomplished by immediate compression with gauze.
Emergency cerebral angiography revealed a pseudoaneurysm in the right internal carotid artery, and pseudoaneurysm trapping (internal carotid artery blockage) with STA-MCA bypass and high flow bypass (ECA-RAG-MCA) was performed. After the operation, there was no apparent paralysis, and MRI revealed no apparent infarct. Four years after the operation, there is no evidence of aneurysm recurrence. This case suggests that in cases that develop refractory epistaxis after head injury, traumatic internal carotid artery pseudoaneurysm must be considered in the differential diagnosis, and cerebral angiography must be performed immediately.
Introduction: Orbital tumors are rare and surgical approaches to the tumors are complicated. Recently, the endoscopic transnasal approach was reported to be effective.
Methods: We reviewed the data of 18 cases of orbital tumors that were operated upon at the ENT department of Hiroshima University between January 1, 2008, and April 30, 2018.
Results: We used the “Round-the-Clock” model to classify the tumor locations. The tumors were located in the 1 to 7 o’clock (12/18 cases, 66.7%), 7 to 9 o’clock (8/22 cases, 27.8%), and 9 to 1 o’clock (1/18 cases, 5.6%) positions. The endoscopic transnasal approach was used in 13 cases, including 11/12 cases with the tumors in the 1 to 7 o’clock position. The tumors included 5 cases of inflammatory tumors, 3 cases of malignant lymphomas, 2 cases of paranasal sinus cysts, 1 case of metastatic orbital tumor, 1 case of cavernous hemangioma, and 1 case of granulomatosis with polyangiitis. There were no cases of serious complications.
Conclusion: Endoscopic transnasal approach is an effective approach for tumors in the medial and lower parts of the orbital cavity. Tumors in the upper-medial part of the orbital cavity can be approached using navigation systems. We consider that minimally invasive surgery is possible if the appropriate approach is used.
We encounterd some cases of sinusitis caused by the landside disaster during the heavy rains that lashed West Japan in 2018. Based on the similar presentation of some cases in Hiroshima Prefecture, we confirmed the diagnosis of sinusitis in five cases. Of the five patients, four had been washed down by the landslide while inside their cars or whole bodies; the fifth case drowned when water entered the car.
CT revealed opacities in the sinuses, accompanied by high-density changes in one part, which was thought to present a mixture of the sand and water. The number of sides of the sinus in which shadows existing was 5 each in the maxillary sinus and ethmoid sinus, four in the sphenoid sinus, and none of the frontal sinus. In 1 case, we recognized a foreign body attached to the anterior wall of the maxillary sinus. From the positional relations of the anterior wall and the natural ostium of the maxillary sinus, we estimated that the foreign body had not entered from the front of the nasal cavity, but from the posterior part of the nasal cavity during strong nasal exhalation after aspiration.
In regard to the clinical progress, three cases were cured by conservative medical treatment, while the remaining two needed endoscopic sinus surgery.
We report a case of an extrapharyngeal fish bone foreign body that needed an external incision for removal. The patient was a 69-year-old man who developed throat pain after eating sculpin soup. He visited our hospital the following day. While computed tomographic (CT) examination revealed a foreign body in the retropharyngeal space, the object could not be detected by esophagoscopy. Therefore, we approached the foreign body via an external incision in the neck, and successfully removed it from the retropharyngeal space. Esophageal foreign bodies sometimes migrate into the extrapharyngeal space. Such patients often complain of several persistent symptoms, such as throat pain and discomfort until the foreign body is removed; fever could also develop in a few patients and should be watched for. If a swallowed foreign body cannot be detected by esophagoscopic examination, CT examination, preferably 3-D CT, should be performed, and an external incisional approach must be considered for removal.
Malignant laryngeal tumors are often squamous cell carcinomas, and the most frequently encountered benign lesions are papillomas. While small benign tumors may be asymptomatic, larger tumors could cause globus pharyngeus, dysphagia or hoarseness, and still larger tumors could even cause respiratory difficulties and suffocation if the tumor blocks the entire larynx.
We report the case of a laryngeal tumor that caused airway constriction and was removed by endoscopic laryngo-pharyngeal surgery (ELPS). The patient was a 40s woman who had visited a hospital in her neighborhood with the chief complaints of hypopharyngeal discomfort and snoring. Since a tumor had been observed in the larynx and there was evidence of airway constriction, tracheotomy was performed and she was referred to our hospital for further management. We observed a tumor in the left arytenoid, and while a preoperative biopsy did not provide any definitive diagnosis, the findings suggested a benign lesion. Although tracheotomy had been performed, as the airway was constricted, we planned surgical removal of the lesion. We judged that full-view observation of the lesion and surrounding area was possible with a Sato curved laryngoscope, and chose ELPS for the procedure. The tumor was removed en bloc by ELPS, without any complications. It was possible to remove the tumor by the endoscopic approach, because the Sato curved laryngoscope allowed a full view of the tumor as well as observation of the basal area of the tumor.
Although resection through an external incision should be considered if it is judged that the Sato curved laryngoscope might not offer a full view of the tumor, there are strong contrast effects and the procedure is associated with a higher risk of hemorrhage. Given the preference for low-invasive surgery, a careful decision should be arrived at during the preoperative meeting.
We devised a safe, minimally invasive surgery for anterior mediastinal goiter, that did not involve sternotomy, through cooperation between the otolaryngologic and thoracic surgical teams. We report the case of a patient with an anterior mediastinal tumor, in which a cervical incision was made by an otolaryngologist and mediastinoscopy was performed by a thoracic surgeon, and the anterior mediastinal tumor was removed collaboratively.
A 61-year-old female patient presented to us with a tumor extending from the superior mediastinum to the anterior mediastinum, posterior to the sternum and anterior to the aortic arch. A thoracic surgeon stripped off the anterior aspect of the mediastinum using a mediastinoscope with CO2 gas, inserted via the lower anterior mediastinum below the xiphoid process.
The otolaryngologist made a transcervical incision, performed tumor exfoliation while taking care to preserve the recurrent and superior laryngeal nerves, removed the portion of the anterior mediastinal tumor via the transcervical incision, and performed a left thyroidectomy. Oral intake was started on the following day. The patient was discharged on postoperative day 7, with no decrease of the thyroid function.
Removal of anterior mediastinal goiter is often difficult. The sternum obstructs the surgical field, necessitating blind removal, which is difficult and risky, because important vessels including the brachiocephalic arteries and innominate veins, and structures such as the thymus are present. Therefore, surgical removal of anterior mediastinal tumors requires safe and reliable sternotomy to preserve the vascular structure and a clear surgical field. However, this procedure is highly invasive for cases of benign mediastinal goiter.
We report our method for reliable tumor removal, in which the tumor is removed via a cervical incision using mediastinoscopic guidance, as a minimally invasive surgery for anterior mediastinal goiter, without the need for sternotomy. Cooperation between the otolaryngologic and thoracic surgical teams during surgery involving the thoracic cavity and mediastinum is important, and this case highlights the importance of teamwork in surgical practice.