A case of bilateral cholesteatomas which caused a cerebellar abscess is reported herein. The patient was a 38-year-old male who had bilateral otorrhea and hearing loss from childhood. He presented with fever, a headache, and vertigo which had started in the summer, and he visited our hospital two months later because the symptoms did not improve. At the first visit, nystagmus was not present. CT images revealed bilateral cholesteatomas, and there was a lateral semicircular canal fistula with expansion of the cochlea and the posterior semicircular canal in the right ear. There was no bone defect of the middle- and post-cranial fossa. At first, we regarded the vertigo as peripheral, and planned a radical operation on the right middle ear. But, after hospitalization, the patient collapsed with a tendency to somnolence and Bruns’ nystagmus. MRI revealed an abscess in the right cerebellar hemisphere. To treat obstructive hydrocephalus and the cerebellar abscess, trepanning ventricular drainage and brain abscess drainage via a craniotomy were carried out. After treatment with antibiotics, the patient’s general state improved. Accordingly, a mastoidectomy with labyrinthectomy was performed on the right ear, and a staged tympanoplasty was carried out on the left ear. There has been no recurrence for three years until the time of writing. We presume that the infection route of this case was the internal auditory meatus. A cerebellar abscess secondary to cholesteatoma is rare, but early examination and treatment are necessary, because the fatality rate in these cases is higher when a brain, especially cerebellar abscess occurs.

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The bone-anchored hearing aid (BAHA) has been used since 1977, and is currently approved for a variety of bilateral hearing loss categories including conductive hearing loss, and mixed hearing loss. The BAHA is also approved for patients with unilateral hearing loss, and this entity occupies one-third of the total number of cases.
In Japan, however, the BAHA has not been approved for patients with unilateral conductive hearing loss and single sided deafness (SSD), because no significant effect could be confirmed based on the results of a prior multi-center clinical study.
In the present study, we re-evaluated the effectiveness of BAHA for the patients with unilateral conductive hearing loss and SSD by adding new test conditions of a speech recognition test in noise and the sound localization test to those tests which were used in the multi-center clinical study.
The results of the speech recognition test in the patient with SSD showed a decrease of 16% in the score with BAHA in noise (+10 dB signal-to-noise ratio) compared in cases without BAHA, when noise was presented on the side of the patient’s poor ear and speech was presented on the side of better ear. On the other hand, in patients with unilateral conductive hearing loss, the score with BAHA increased 2% compared in cases without BAHA.
As to the result of the sound localization test, in the patient with SSD, the mean absolute error (MAE) was 45° with BAHA and 52.5° without BAHA. On the other hand, in the patient with unilateral conductive hearing loss, the MAE was 26.1° with BAHA and 36.9° without BAHA.
In other words, the effectiveness was reversed for each of the pathological conditions in the present study. We think that these results are derived from the difference of the subject’s having only one functioning inner ear in SSD but having bilateral functioning inner ears in unilateral conductive hearing loss. Therefore, the effectiveness of BAHA should be evaluated separately in patients with unilateral conductive hearing loss and SSD even in cases showing similar hearing disturbance.

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Currently, bilateral cochlear implantation (BCI) in children is reimbursed in Japan, and unilateral cochlear implantation (UCI) has been the standard treatment for profound deafness. In the present study we assessed three school-aged children who underwent BCI at about 8 years of age, 6 years after first implantation to determine whether BCI was associated with improved listening skills, performance under noise, and higher general quality of life compared with UCI. Our results showed that the children did not become accustomed to the second implant for the first few months, but noticeable improvements in listening abilities were made by 6 months. The ability to hear monosyllables, words, and sentences with the second implant showed almost the same results as the first implant after 6 months to 1 year. Overall, BCI was considerably beneficial to improve speech performance in 2 of the 3 children under noise, although the third child still exhibited relatively good results (S/N ratio, 0 dB). Our findings also indicated that BCI could aid in the development of spoken language skills in hearing-impaired children. The PVT (Picture Vocabulary Test) or PVT-R (Picture Vocabulary Test-Revised) results of all three children increased after the second surgery. The children’s parents and teachers also recognized changes in participation in school activities.

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The opsoclonus-myoclonus syndrome (OMS) is characterized by subacute onset of opsoclonus, a disorder causing of saccadic eye movements causing involuntary, chaotic saccades that occur in all directions.
We report herein on a 36-year-old man with mainly horizontal chaotic saccades after truncal ataxia. Intravenous corticosteroids pulse therapy was very effective and his opsoclonus disappeared. No malignant tumors were detected with positron emission tomography. We analyzed eye movement using electronystagmography (ENG) and considered this case to be one of non-paraneoplastic OMS.

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We often encounter clinical cases with nystagmus or abnormal eye movements that are suspected to be associated with central vertigo. However, imaging techniques such as magnetic resonance imaging (MRI) may not always yield abnormal findings for such cases. For two patients who were suspected as having central vertigo on the basis of oculomotor testing but had normal MRI findings, we identified the lesion site using the results of neuro-otological tests. (1) Since direction-changing positional nystagmus was observed, with inhibited optokinetic nystagmus or saccadic pursuit, we suspected cerebellar or brain stem lesions. (2) Caloric testing yielded a normal response. Hence, the vestibular nucleus, abducens nucleus, oculomotor nerve nucleus, and medial longitudinal fasciculus were considered to be lesion-free. Visual suppression was also normal; this allowed us to rule out the pons, cerebellar flocculus, and nodulus as lesion sites. Moreover, preserved saccadic speed indicated no damage to the pons or midbrain. (3) Because hypermetria was observed during the saccade, we suspected damage to the cerebellar fastigial nucleus. Further, drift to the median during the saccade and gaze-evoked nystagmus were observed, suggesting a lesion in the nucleus prepositus hypoglossi, which is a neural integrator. Both our patients showed poor laterality; therefore, they were thought to have a degenerative disease. From the above-mentioned findings, we propose that MRI cannot reveal any abnormalities during the very early stages of spinocerebellar degeneration.

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We report herein on our experience in one case of cerebellitis in which the presence of flutter-like oscillation (FLO) helped in the diagnosis and treatment. A 59-year-old man underwent a medical examination for gait impairment. He presented with transient, horizontal and pendular ocular oscillation. This abnormal eye movement was diagnosed as flutter-like oscillation (FLO). The abnormal ocular motion was a characteristic finding in his neuro-otological findings, and although cell counts and protein concentration in his cerebrospinal fluid were significantly elevated, the results of his blood test and brain MRI findings (diffusion-weighted image, Gd-enhanced T1-weighted image) were unremarkable. Brain perfusion scintigraphy revealed modest increase in cerebellar blood flow. After treatment with intravenous immunoglobulin and immunoadsorption therapy, the FLO disappeared. FLO is a rapid abnormal ocular movement to the left and right of the transient lasting for a few seconds. These are important findings when making the diagnosis. FLO has been reported to be mostly due to a cerebellar deficit. Cerebellitis is a disease that is mainly associated with trunk ataxia, poor coordination of the extremities, dysarthria, and abnormal ocular movements. In many cases, cerebellitis is preceded by symptoms of infection symptoms preceding, but many cases have also been reported where such symptoms are unclear. As for the pathogenesis of cerebellitis, direct bacterial and viral infection, a post-infection-associated immunological mechanism of and activation of a subclinical virus have all been considered. We could not find any obvious signs of a preceding infection in our case and various virus antibodies were also negative. Although the findings of protein cell dissociation were recognized in the cerebrospinal fluid examination carried out as one of the assessments, the cerebellitis in this patient was identified by immunologically. Our results suggested that a diagnosis of cerebellitis could be important for the observation of ocular movement.

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We report herein on two cases of ANCA-associated middle ear disease. Case 1: A 31-year-old female first complained of left earache and left aural obstruction with an increase in serum levels of PR3-ANCA. Case 2: A 78-year-old female first complained of bilateral ear discharge and hearing loss with an increase in serum level of MPO-ANCA. In both cases, we clinically suspected ANCA-associated middle ear disease and administered steroids and an immunosuppressant. In case 1, the patient was making steady progress as regards the local symptoms. In case 2, bilateral facial paralysis had developed two months after the start of the therapy. In neither case did aggravation of the general symptoms develop.
In the treatment of ANCA-associated middle ear disease, we must follow up carefully long enough to prevent development of hearing loss and facial paralysis.

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Small-fenestra stapedotomy (SFS) is generally regarded as a first-choice procedure in terms of minimizing postoperative dizziness and improving hearing levels. However, otosclerotic changes to the footplate are relatively mild in most Japanese patients. The CO₂ laser has been widely used for management of the nasal mucosa in Japan. This study examined whether the CO₂ laser could cut the crus bones to keep the footplate in place. This study evaluated data from 63 patients who had undergone stapes surgery with the CO₂ laser between October 2010 and December 2013. A transcanal approach was adopted under general anesthesia. The stapes tendon and posterior crus were cut with the CO₂ laser. The anterior crus was cut with the laser or was fractured. A Skeeter^TM drill or CO₂ laser was used to open the stapes footplate, and a piston was then inserted. SFS was performed in 50 patients (79%), partial stapedectomy in 9 (14%) and total stapedectomy in 4 (6%). Between 1999 and 2009, SFS was performed in 54 of 97 patients (56%), partial stapedectomy in 26 (27%), and total stapedectomy in 17 (18%). The postoperative air-bone gap was ≤10 dB in 33 cases (79%), 11-20 dB in 8 cases (19%), and >30 dB in 1 case. The rate of stapedotomy was significantly increased compared with the procedure without using a CO₂ laser. Therefore, these results suggest that a CO₂ laser can be used to cut the stapes crus during stapedotomy.

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We report herein on a patient with extranodal non-Hodgkin’s lymphoma in Stage IV whose only symptoms were otitis media with effusion and combined hearing loss in the affected side. A 64-year-old female came to our hospital with right ear fullness, and the clinical examination revealed otitis media with effusion and combined hearing loss in her right ear. No tumor lesion was found in nasopharyngeal endoscopy. Since conservative treatment was not effective, a tympanostomy tube was inserted. Because her hearing did not recover well compared with her unaffected side, computed tomography (CT) of the head was performed, which showed a tumor lesion surrounding the internal carotid artery and extending to the cavernous sinus. Since malignant lymphoma was suggested from the CT findings, ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) was performed which revealed the accumulation of FDG not only from around the internal carotid artery to the cavernous sinus but also some to portions of the cranium, pelvis, lumbar vertebrae, and head of the femur. No neurologic findings and symptoms associated with osseous lesion were found except hearing loss. An excisional biopsy from the iliac bone gave the pathological diagnosis of non-Hodgkin’s lymphoma, low grade B cell lymphoma. The patient underwent eight sessions of R-CHOP chemotherapy (rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisolone). Chemotherapy was effective and all her tumor lesion including intracranial, extracranial, and osseous lesions disappeared and her hearing ability also recovered. There has been no sign of recurrence so far. Since local symptoms of the head and neck region can sometimes indicate general disease, otorhinolaryngologists should have a wide perspective, make an accurate diagnosis and deal adequately with any disease.

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We report herein on a rare case of cavernous hemangioma of the facial nerve. The patient was a 75-year-old woman with a first episode of facial nerve paralysis who was being treated with steroid pulse therapy. However, the paralysis failed to improve and had become exacerbated during the previous few years. Ultimately her facial score was 0/40 points by the Yanagihara method. CT imaging demonstrated a tumor at the tympanic to horizontal part of the facial nerve. MRI imaging demonstrated an enhanced lesion measuring 4×7×7 mm. A facial nerve schwannoma was suspected, and the tumor was totally removed via the transmastoid approach. Based on the histopathological examination the diagnosis was a cavernous hemangioma of facial nerve origin.

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An 83-year-old woman was referred with right-side nasal obstruction. The CT scan showed a 60×45×43 mm mass arising from the nasal septum. MRI imaging indicated a smooth and encapsulated mass partial cystic formation involving 30×30×24 mm. A pre-operative definitive diagnosis could not be made despite two biopsies. We performed an endoscopic intranasal operation in combination with a midfacial degloving approach. The post-operative final diagnosis was pleomorphic adenoma (PA) of the nasal septum. Nasal septal PA is exceedingly rare, and only a few cases of giant PA tumor have been reported previously. In this case, we could achieve complete en bloc excision via minimal invasive surgery without facial skin incision. Intranasal PAs have a pathologic feature which seems to be composed of higher epithelial and lower stromal components than PAs of the major salivary glands. The possibility of PA should be kept in mind when assessing nasal cavity tumors that are rich in epithelial constituents. Sometimes small cysts are formed in PAs, while a cyst large enough to be recognized macroscopically is rare. This is the first case report of a nasal septum PA accompanied with cyst formation.

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Intranasal steroids are widely used to treat olfactory disorder, and are known to have fewer side effects than systemic steroids. However, there are some reports that intranasal steroids have induced adrenal insufficiency, even when the steroid dosage is appropriate.
We encountered a case of secondary adrenal insufficiency after using intranasal betamethasone for olfactory disorder within the usual dosage. In this case, we were not aware of instructing the patient not to swallow the steroid which had dripped into her pharynx. Thus, a large amount of steroids which had passed through her nasal cavity might have been absorbed in the oropharyngeal mucosa and also ingested. That is possibly the main cause of developing adrenal insufficiency.
Recently, Toki-shakuyaku-san, a traditional Chinese medicine, has started to be used for olfactory disorder after a cold. Because of its minimum side effects, it may be safely used for patients with the risk associated with steroid use.

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Pyogenic granulomas are a benign vascular tumor of the skin and mucous membranes commonly affecting the oral cavity, and less commonly the nasal cavity. Their etiology is unknown, however, pyogenic granulomas have been closely related to pregnancy. We report herein on a 31-year-old pregnant woman with a rapidly growing hemorrhagic lesion within the nasal cavity, which required pre-operative embolization and subsequent endonasal excision under general anesthesia after delivery of a child. In this report, we discuss the clinical figures, radiological and histological characteristics of pyogenic granulomas, and their treatment strategy.

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Since Streptococcus pneumoniae has severe pathogenicity and the incidence of penicillin-resistant S. pneumoniae has been increasing, it is important to identify S. pneumoniae rapidly as the pathogenic bacterium to enable appropriate antimicrobial treatment. However, especially in the case of pediatric rhinosinusitis, S. pneumoniae is one of the normal inhabitants of the nasopharynxes, so it is difficult to identify it as a pathogenic bacterium. We investigated the usefulness of a pneumococcal antigen detection kit, RAPIRAN^® S. pneumoniae HS (HS kit) for the detection of pathogenic bacteria associated with acute rhinosinusitis.
We have evaluated 134 nasopharyngeal secretions (72 children, 62 adults), and have examined the HS kit, culture test and microscopic examination (Gram stein), and made comparisons among them.
The positive rate of the HS kit was 38.9% in children, and 6.5% in adults, with a sensitivity of 65.2%, a specificity of 97.7% and a concordance rate of 86.6%. Furthermore, in the culture test, the HS kit(+) dominant bacterium was S. pneumoniae, whereas the HS kit(–) dominant bacterium were Haemophilus influenzae and Moraxella catarrhalis.
Based on our results, we concluded that the HS kit could be useful for the detection of pathogenic bacteria associated with acute rhinosinusitis, so that if the HS kit is positive, the pathogenic bacterium is probably S. pneumoniae, and if the HS kit is negative, the pathogenic bacteria are probably others, with the exception of S. pneumoniae.

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Juvenile angiofibromas represent a rare vascular tumor of the deep part of the face occurring in adolescent males. This tumor typically arises from the sphenopalatine artery. The surgical approach for the tumor requires consideration for both complete removal of the tumor and preservation of the facial appearance.
We applied the hemifacial degloving approach in a 12-year-old boy with a unilateral juvenile angiofibroma staged IIIA according to Radkowski (1996). We performed this approach twice on this patient because we had missed the residual tumor inside the base of the right pterygoid process at the first surgery. He has had no evidence of recurrence of the tumor and no surgical marks on the face over three years after the second surgery. Hemifacial degloving is a more suitable approach than midfacial degloving for exclusively unilateral tumors.

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Allergic rhinitis is one of the most common diseases in Japan. Various allergens can cause allergic rhinitis. Dactylis glomerata allergen has been known as one of the major causes of allergic rhinitis. The present study discusses the sensitization of D. glomerata allergen in 1927 patients treated at the Department of Otolaryngology of Kawasaki Medical School between 2000 and 2012, who were tested for serum specific IgE antibodies using the CAP-radioallergosorbent test. The sensitization by D. glomerata allergen was found in 570 patients (male 318 patients, female 252 patients). Great fluctuations were not seen in the sensitization in these thirteen years. The peak age for the positive rates for D. glomerata was between the ages of 10 and 19 years old. Single sensitization was found in the small number of 25 patients.

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Infant chronic rhinitis (ICR) is frequently encountered in routine clinical practice in the otorhinolaryngology department, but its detailed pathology is unknown.
In this study, 3396 children aged 6 or younger who initially visited MORI Otorhinolaryngology & Allergy Clinic were analyzed, 82.2% of whom chiefly complained of nasal symptoms. Over 70% of the children presented with a disease duration of up to 2 weeks, as determined based on their medical interviews. Among those, 75.7 to 84.2% were diagnosed as having apparent chronic nasal disease or had symptoms persisting at follow-up visits.
Excluding 639 children diagnosed with perennial allergic rhinitis (PAR) at the initial visits among the 3396 children, we performed a prospective cohort survey in 2757 children. The results demonstrated that children with versus without ICR showed a significantly higher incidence of PAR (P<0.001). A multivariate analysis revealed that the following variables were significantly correlated with PAR onset; “previous ICR episode” (odds ratio: 7.948; P<0. 001), male (1.712; P=0.004), family history of allergy (4.858; P<0.001), previous history of allergy (10.414; P<0.001), and positive for eosinophils in the nasal discharge (7.283; P=0.005).
In addition, 343 of the 364 children with acute otitis media (AOM) had complicating nasal diseases. The majority of these children followed the course of ICR despite a disease duration of 2 weeks or shorter based on their medical interview. Although 87.0% of the children with AOM showed immediate improvement with treatment using antibiotics such as AMPC and CDTR-PI, those complicated with ICR responded poorly to this treatment. Also in the group of children complicated with AOM, the variable “previous ICR episode” was significantly correlated with a higher incidence of PAR (odds ratio: 2.656; P=0.005).
These results suggest that ICR is essential for the growth-related onset of PAR and constitutes the pathology of PAR.

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Sarcoidosis is a multisystem granulomatous disorder of unknown origin. Sarcoidosis can affect the nasal mucosa and result in acquired nasolacrimal duct obstruction that induces epiphora and dacryocystitis. We report herein on a 41-year-old man with nasolacrimal duct obstruction secondary to sarcoidosis. He had pulmonary sarcoidosis when he was 22-year-old. He underwent septoplasty and turbinectomy for nasal obstruction at the age of 29. Histopathological examination showed non-caseating epithelioid granuloma resulting in nasal sarcoidosis. Epiphora in both eyes developed and an endoscopic-dacryocystorhinostomy was performed bilaterally at the age of 41. His nasal cavity was deformed and the mucous membrane was hypertrophic. We used a navigation system and a 25G light guide to establish orientation. A 2.5 mm diamond bur was used for the dacryocystorhinostomy. A Nunchaku-type silicon tube was inserted successfully in the left side, but was inserted only half way in the right side. The left and right tubes were removed a month and 3 months after surgery. The symptoms of the left eye disappeared after one year but the symptoms of the right eye remained.

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The blood boil is a benign hemorrhagic pseudotumor that usually arises in the sinonasal tract, particularly the maxillary sinus and blood boils in the frontal sinus are very rare. We experienced a rare case of a blood boil in the frontal sinus. A 55-year-old female visited our hospital because of a swelling in her forehead and lateral deviation of the left eye. CT and MRI showed a large mass extending from the left frontal sinus to the orbital roof with bone erosion. Because of poor improvement with conservative medical treatment, we performed a frontal sinus operation via the transcranial approach and removed the tumor. Histopathologically, the tumor was composed of necrotic tissue with hemosiderin deposition and no malignant tissue, and it was diagnosed as a blood boil in the frontal sinus. No recurrence has been seen for about 1 year after the operation.

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Supplied-air hood respirators are used when working with abrasive blasters. The hood covers the head, neck, and upper torso, and usually includes a neck cuff. Clean air is delivered by a compressor through a hose leading into the hood. The hood is not tight-fitting. Sufficient air is provided to maintain a slight positive-pressure inside the hood relative to the environment outside the hood. In this way, an outward flow of air from the respirator will prevent contaminants from entering the hood. This positive-pressure inside the hood exerts pressure on the skin but does not usually cause subcutaneous emphysema. However, we report herein on a case of subcutaneous emphysema of the face caused by using a supplied-air hood respirator. The lift developed by the airflow between the face and the hood possibly induced the subcutaneous emphysema in spite of the positive-pressure inside the hood.

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The middle meatal mucosa, uncinate process, infundibulum, superior meatal mucosa and sphenoethmoidal recess are the most common sites of origin of polyps. Polyps originating from the mucosa of the nasal septum are rare. We report herein on a case of bilateral nasal polyps originating from the nasal septum.
Case report: A 39-year-old woman visited our hospital complaining of nasal obstruction. The patient had lateral nasal septal polyposis which filled nasal vestibule.
She had a history of perennial allergy rhinitis and asthma. Computed tomography (CT) showed nasal septal polyposis filling the nasal pathway without bone destruction.
She was treated with a corticosteroid nasal spray, oral antihistamine therapy and oral clarithromycin therapy for three months but without any improvement in her symptoms.
As nasal septal polyps are a rare entity and the potential of malignant disease was considered, we performed a biopsy. Nasal polyps with an inflammatory response were diagnosed based on the histopathological examination. Endoscopic surgery was performed using a microdebrider under general anesthesia.
After surgery, the patient was treated with oral antihistamine therapy, oral steroid therapy and a corticosteroid nasal spray. At two weeks postoperatively, she discontinued the oral steroid use. At six months postoperatively, she discontinued the oral antihistamine drug.
After 24 months follow up, there was no evidence of recurrence.

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Concurrent superselective intra-arterial chemoradiotherapy (SIACRT), a combination of chemoradiotherapy (CRT) and superselective intra-arterial chemotherapy (SIAC), is a new therapeutic strategy for advanced squamous cell carcinomas (SCCs) of the head and neck. We have been applying SIACRT for SCC of the maxillary sinus and upper gingiva since 2008 and present herein the outcomes at our hospital. SIACRT was applied in 10 cases between 2009 and 2012, 7 males and 3 females with an age-range of 57 to 81. An intra-arterial micro-catheter was inserted into a feeding artery of the tumor super-selectively using Seldinger’s method. Cisplatin (CDDP) was injected into the tumor intra-arterially through the catheter at a rate of 5 mg per minute. At the same time sodium thiosulfate (STS) was intravenously administered at 200-fold the dose of CDDP in a molar quantity to reduce the toxicity of the CDDP. Irradiation was started on the same day.
Five-day-continuous intravenous administration of 5-fluorouracil (5FU) was started the next day. CDDP and 5FU were administered in the same way four weeks later. The total dose of irradiation was 50 to 60 Gy. In eight cases, the protocol was applied correctly, and these patients showed complete response (CR) and survived without disease for more than 15 months. In two cases, the patient dropped out of the protocol, resulting in partial response (PR). Of these cases, one refused the 2nd administration of SIAC and in the other two courses of SIAC followed by SIACRT were administered. In two of the eight CR cases, the application of SIACRT eliminated metastatic lymph node tumors.

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Sinusitis is commonly found, but lesions localized in the sphenoid sinus are rarely associated with sinusitis. We report herein on 21 cases of isolated sphenoid sinus disease (ISSD) treated surgically at the Department of Otolaryngology, Yamaguchi University, Graduate School of Medicine between March 2008 and March 2012. Diagnosis was made on the basis of history, clinical signs, nasal endoscopy, and imaging techniques with CT/MRI. The final diagnosis of ISSD was established after histopathological examinations of the excised surgical specimen. The pathologies included fungal diseases (48%), sphenoid sinusitis (28%), sphenoid cysts (19%), and tumorous tissue (5%). The initial symptom was headache (62%), followed by rhinorrhea (19%). An endoscopic sphenoidectomy was performed through the nasal septum in 15 patients and was useful for total removal of the lesion.

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We experienced a patient with sphenoid sinus metastasis from prostatic adenocarcinoma. A 75-year-old man suffering from diplopia for one month was diagnosed as having left abductor paralysis by an ophthalmologist. He was referred to our department, because the cause of the left abductor paralysis was suspected as being due to opacification at the bilateral sphenoid sinus seen on CT imaging. We performed a nasal septoplasty and endoscopic sinus surgery (ESS) under local anesthesia. A reddish brown tumor in the sphenoid sinus was bilaterally observed during surgery. The tumor was histologically diagnosed as an adenocarcinoma metastasized from prostatic cancer. The left abductor paralysis gradually improved following treatment by medical oncologists after chemotherapy using docetaxel. Sinonasal CT imaging also showed a reduction of the tumor volume in the sphenoid sinus lesion. However, the patient represented with right facial palsy in the seventh month after surgery. Finally, he died of respiratory dysfunction caused by metastatic cancer to the lung.

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We describe herein a rare case of a traumatic pseudoaneurysm affecting the maxillary sinus. An 83-year-old man presented with intractable epistaxis was admitted to our hospital. He had fallen down, hitting his face on the ground three days before hospitalization. He presented with epistaxis that could be controlled with anterior nasal packing, however, his blood tests revealed anemia which became worse in 24 hr. Paranasal sinus CT imaging showed a mild bone fracture of the maxillary sinus and a hematoma in the maxillary sinus, so we performed contrast-enhanced CT (CECT) to verify the active bleeding site. The CECT showed that there was a pseudoaneurysm affecting the maxillary sinus. To confirm the bleeding site, angiography was performed. Angiograms showed a pseudoaneurysm arising from the right posterior superior alveolar artery. The patient successfully underwent transarterial embolization therapy to control the bleeding.

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In the present study, we assessed the efficacy of cefteram pivoxil in children with moderate or more severe acute rhinosinusitis. In addition, we evaluated the efficacy of clinical scoring systems based on clinical symptoms and the condition of the individual patient. Cefteram pivoxil administered at 18 mg/kg/day showed better efficacy and rapid onset of action. Moreover, clinical scoring systems enabled us to evaluate the condition and symptoms chronologically. This result suggested that the clinical scoring systems were useful for clinical efficacy assessment in pediatric acute rhinosinusitis.

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IgG4-related disease is considered to be a systemic disease characterized by a high serum IgG4 level and IgG4-positive plasma cell infiltration into the organs of concern. In the head and neck regions, Mikulicz disease has come to be associated with IgG4-related diseases. We report herein on five cases of patients with IgG4-related disease with bibliographic consideration. Patients with this disease, but showing only the swelling of the salivary glands, may be treated conservatively with only careful follow-up. However, when serious systemic symptoms such as pancreatitis occur during the clinical course of a case of IgG4-related disease, early diagnostics and follow-up in consultation with other specialists are recommended.

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Hamartomas of the tongue in children are rare. We report herein on a 3-year-old Japanese boy with hamartoma presenting with a pink smooth surface at the middle (15×7×7 mm) and lateral edge (20×30×15 mm) of the tongue.
The tumor was apparent from birth and had increased in size as the patient grew. He felt uncomfortable when he chewed food. There was no family history of tongue tumors. There were no abnormal findings in the mouth, nose, ear, head, neck and cervical lymph nodes and the laboratory data were normal. The tumors were resected with a safe margin of three mm under general anesthesia. The tumor had not invaded the tongue muscle. The pathological diagnosis was hamartomatous tissue with bundles of smooth muscle fiber. The remnant tongue has been operating well for a year after surgical treatment, and the tumor has shown no evidence of recurrence.

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We retrospectively analyzed the medical records of 28 patients who underwent surgical extraction of sialolithiasis in the submandibular gland or at the junction of the duct and gland at the Sano Kosei General Hospital Department of Otorhinolaryngology between April 2003 and March 2014. Glandular stones were observed in 7 patients and at the junction in 21. Twenty-two patients had 1 stone; 5 had 2 stones; and 1 had 3 stones. In 21 patients, the maximum diameters of the 25 stones as measured by computed tomography (CT) were <5 mm for 5 stones, 5 to <10 mm for 7, 10 to <15 mm for 9, and ≧15 mm for 4. Preoperative bidigital palpation detected palpable stones in 19 (palpable group) and non-palpable stones in 6 patients (non-palpable group), while stones in 3 patients could not be determined. Of these 28 patients, 24 chose intraoral surgical treatment, while 4 chose submandibular gland extraction. In 23 of these 24 patients who underwent intraoral treatment, the stones were extracted as planned; in the remaining case, the stone was excreted naturally post-operation. All patients showed favorable postoperative progress. The postoperative complications in the intraoral treatment included temporary submandibular swelling in 7 patients, persistent pain in 4, and transient glossal nerve paralysis in 3, but no permanent complications. However, the non-palpable group had significantly longer operative durations and a higher incidence of complications.
Intraoral surgical treatment can be used as the first-line therapy for sialolithiasis in the submandibular gland or at the junction of the duct and gland. Although intraoral treatment is possible in the non-palpable group, patients should be adequately informed about the complications risks, and their wishes, sex, and social background should be considered before performing this method.

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We have examined the diagnostic accuracy and usefulness of fine needle aspiration cytology (FNAC) for parotid tumors. Forty-nine patients received preoperative FNAC and surgery between August 2008 and May 2012 at Tokyo Medical University Hachioji Medical Center. Twenty-six were males and 23 were females with a mean age of 60.7 yr. FNAC was performed with a 21G needle under ultrasonography. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of a benign or malignant diagnosis were 90%, 97%, 90%, 97% and 96%, respectively. Preoperatively, 39 lesions were diagnosed as benign: 23 pleomorphic adenomas, 7 Warthin’s tumors, 1 basal cell adenoma and 8 others. One of the 23 diagnosed as a pleomorphic adenoma turned out to be salivary duct carcinoma. Preoperatively, 10 were diagnosed as malignant: 2 salivary duct carcinomas, 2 squamous cell carcinomas, 1 acinic cell carcinoma, 1 mucoepidermoid cell carcinoma, 3 adenocarcinomas and 1 lymphoepithelial carcinoma. One patient diagnosed as having lymphoepithelial carcinoma turned out to have a Warthin’s tumor. FNAC is useful for preoperative diagnosis and therapeutic planning for parotid gland tumors.

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Some cases of squamous cell carcinoma (SCC) arising in free flaps have been reported by several authors. We report herein two cases of squamous cell carcinoma arising in free flaps after oral reconstruction.
The first case was a 76-year-old woman. Nine years before admission, she received resection of a left buccal mucosal SCC and left radical neck dissection. The defect was reconstructed with an anterolateral thigh flap. On a routine examination, a new SCC was noted in the center of the anterolateral thigh flap. The tumor was simply resected. After resection of the SCC, there has been no recurrence for 15 months.
The second case was a 70-year-old woman. Nineteen years before admission, she received resection of an SCC of the right tongue after radiotherapy, and the defect was reconstructed with a forearm flap. She subsequently received tumor resection of an SCC of the left tongue. Four years before admission, right SCC was found in the lower gingival tissue, and she received both radial neck dissection and mandibulectomy. The defect was reconstructed with an anterolateral thigh flap. On a routine examination, a new SCC was noted between the left tongue and the anterolateral thigh flap. The SCC was resected with safety margin. After resection of the SCC, the patient is alive no recurrence for 9 months.
Long-term follow up of these patients demands careful examination of the mucosa of upper digestive tract and the surface of the flap used for reconstruction.

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Malignant myoepithelioma is a rare tumor that occurs in about 0.2% of the salivary gland tumors. We report herein on a case of malignant myoepithelioma which presented in the hard palate.
The patient was a 54-year-old woman, who visited our outpatient clinic with a complaining of nasal obstruction. Rhinology showed an elevation of the nasal cavity floor, and a 15 mm mass lesion was observed in hard palate.
The presence of tumor was confirmed by CT imaging on which a large solid mass occupying part of right maxillary sinus, hard palate, and nasal cavity were observed. There were no palpable neck lymph nodes. The pathological diagnosis of a biopsy taken from the nasal cavity floor was malignant myoepithelioma. Immunohistochemical studies showed positive staining for keratin and p63, and partial positivity for S-100 and GFAP.
The patient underwent subtotal maxillectomy of the right maxilla and partial maxillectomy of the left maxilla.
In a 2-year follow up after the surgery, there has been no evidence of recurrence.

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To predict the histological type of parotid salivary gland tumors, dynamic-enhanced MRI could be useful. Eight patients with parotid salivary gland tumors were examined preoperatively using gadolinium-enhanced dynamic MRI. The time of peak enhancement (T peak) and washout ratio (WR) were determined from time-signal intensity curves (TSI-curves). According to previous reports, we categorized our 8 patients into four main patterns based on the T peak and WR. Type A (T peak>120 sec) was the pleomorphic type, type B (T peak≦120 sec, WR≧30%) was the Warthin tumor type, type C (T peak≦120 sec, WR<30%) was the malignant tumor type, and type D (flat) was not enhanced. According to the pathological diagnosis, the tumors of patients study comprised four cases of pleomorphic adenomas, two cases of Warthin tumors, one case of sebaceous lymphadenoma and one case of salivary duct cysts. While all four cases of pleomorphic adenoma were categorized into type A, one sebaceous lymphadenoma case, a rare benign salivary gland tumor, was categorized into type B (pattern of Warthin tumors). We obtained basically the same result as previous reports on categorization. On that basis, we were able to examine the histological type of sebaceous lymphadenomas using dynamic contrast-enhanced MRI.

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Peritonsillar abscesses are the most common deep neck infection in adults, however, bilateral cases are rare. We report herein on five patients who were diagnosed as having bilateral peritonsillar abscesses. In three of the five cases, we could not at first make a diagnosis of bilateral peritonsillar abscesses, but we suspected tonsillitis based on no laterality in the appearance of the pharynx before the CT scan.
However, CT scan in these patients showed bilateral peritonsillar abscesses. Along with intravenous administration of antibiotics, removal of the abscesses was performed by needle aspiration in one case, and incision for drainage in four cases. Interval tonsillectomy was carried out in three cases.
Enhanced CT should be considered in patients presenting with high fever, severe throat pain, high values of C-reactive protein & white blood cells, and dyspnea.

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Stevens-Johnson syndrome (SJS) is a severe immune-mediated cutaneous and mucous membrane reaction that is usually induced by drugs. We report herein on a case of SJS, which was difficult to diagnose. A 24-year-old man had congestion in both eyes a week prior to admission. The patient had high fever and a sore throat. Although he was being treated with antibiotics and painkillers for tonsillitis in a nearby hospital, his condition did not improve. He was referred to our hospital with conjunctivitis in both eyes and significant swelling and erosion of the nasal, pharyngeal, and laryngeal mucosa. After admission, the mucosal lesions were further exacerbated and the high fever remained. We believed that infection, autoimmune disease, or drugs were the cause; therefore, we did a biopsy of the buccal mucosa on the fifth hospital day and, based on the pathological findings, a diagnosis of SJS was made. After diagnosis, the patient’s condition improved without the need of steroids, but he had erythema with papules on his back on the eighth hospital day. The cause of this was unknown but his condition improved a few days after discontinuation of the antibiotic.
There was no history of exposure to the drugs before the appearance of eye symptoms in this case. SJS may be caused by vaccinations, infection, or various diseases. Erythema multiforme major is generally characteristic of SJS; however, there are few reports of cases where the characteristic rash is delayed or absent. In these cases, the mortality rate and sequelae increase because the diagnosis is delayed. Therefore, in cases with advanced membrane lesions which are continuous from the transition of the cutaneous and mucous membranes, it is necessary to keep in mind that SJS is a possibility and a mucosal biopsy should be considered for early diagnosis even in cases with no rash or no drug exposure history.

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The incidence of oropharyngeal carcinoma has been increasing in Japan. We retrospectively analyzed 72 fresh cases of oropharyngeal carcinoma who were treated between 2005 and 2012 in our department. The subjects were 57 males and 15 females, aged 39 to 84 years with an average of 63.8 years. Sixty-five patients (90.3%) were in stages III/IV. The overall 5-year crude survival, disease-specific survival and local control rates determined by the Kaplan-Meier method were 46.4%, 61.4% and 70.3%, respectively. Both survival and local control rates were significantly higher in patients with T1/2 than in those with T3/4. Of 35 patients with T1/2, 27 (77.1%) were N(+). Twenty-two patients (30.6%) underwent surgery for the primary lesion, and in most of the other 50 patients, complete response of the primary lesion was obtained by chemoradiotherapy without surgery. These results indicate that oropharyngeal carcinomas are prone to metastasize to regional lymph nodes even if the primary lesion is small, but small primary lesions still lead to a good prognosis. The present data also suggested that oropharyngeal carcinomas are highly sensitive to chemoradiotherapy. A better prognosis and functional preservation may be achieved by detecting early primary lesions and distinguishing chemoradiotherapy-sensitive and insensitive cases in the future.

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Actinomycosis is a chronic suppurative granulomatous infection caused by the Actinomyces genus comprising filamentous and gram-positive bacteria that can cause chronic inflammatory granulomas. Actinomyces genus are bacteria resident in tooth sockets or the tonsils. Therefore actinomycosis occurs most commonly in the head and neck region, and in the other cases occurs in the chest and the abdomen.
We report herein on a case of a 66-year-old woman who was diagnosed as having actinomycosis involving the soft palate based on data reported hereunder. Her main complaint was a sore throat. We found a mass-related lesion with a white moss-like substance to the right side of the soft palate. Based on the biopsy findings revealed the histological diagnosis was actinomycosis. We gave her amoxicillin for three weeks, and she was cured. In the six months to time of writing, no recurrence has been noted.
Actinomycosis is an inflammatory mass-forming disease, and diagnosis is difficult when based only on the clinical evidence.

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Traumatic retropharyngeal hematomas are rare but potentially life-threatening conditions. I present herein on the case of a 75-year-old man with a traumatic retropharyngeal hematoma and upper airway obstruction. While driving a car, he fell into a river from a height of 1.5 m, and his face struck the steering wheel, causing bruising. He received anti-platelet therapy, but suddenly complained of severe dyspnea. Computed tomography of the neck showed a large retropharyngeal hematoma so an emergency tracheostomy was performed. Moreover, I treated him with antibiotics and high calorie infusion. The hematoma disappeared after 51 days with close observation. We should keep in mind that retropharyngeal hematomas can occur in elderly trauma patients who are receiving anti-platelet therapy.

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In Japan, patients with peritonsillar abscess are usually hospitalized. In contrast, ambulatory management has been performed in other countries. Patients seek safe, inexpensive, convenient, and shorter periods of treatment. We compared the therapeutic effects between ambulatory and hospitalized care in patients with peritonsillar abscess of a moderate degree.
The subjects, recruited between January 2009 and October 2012, comprised 125 patients with peritonsillar abscess (95 men and 30 women) consisting of 70 hospitalized patients and 55 ambulatory care patients with ages varying from 17 to 89 years old. Of the 125 patients, 74 were affected on the right side and 51 on the left. The ratio of smokers was 63% in men and 20% in women. All patients were treated with antibiotics and aspiration for drainage of abscess. Both SBT/ABPC and CLDM were most frequently administered. The average number of aspiration treatments was 3.04. Peritonsillar abscess recurred in 19 cases (19%), while 14 cases (14%) had recurrence within one month after discharge.
The therapeutic effect was compared regarding the recovery period, inflammatory parameters, and the number of aspiration treatments. The clinical outcome showed no statistically significant difference between the ambulatory and hospitalized care groups. We concluded that ambulatory therapy is as effective as and less expensive than hospitalized care in moderate and mild cases of peritonsillar abscesses.

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Croup is an acute respiratory tract inflammation characterized by swelling of the subglottic tissue caused by an infection with respiratory viruses such as parainfluenza virus, influenza virus, adenovirus and respiratory syncytial virus. Its symptoms include fever, barking cough, stridor and hoarseness. It is a relatively common condition in childhood, especially at younger than three years of age. Since it rarely occurs in adulthood, the clinical features of adult croup are mostly unknown. We report herein on three cases of adult croup and review another 17 cases of adult croup described in the literatures written in English or Japanese. The clinical features of adult croup were compared to that of croup in children. The patients with adult croup present with symptoms such as sore throat and dysphagia in addition to the symptoms that are common for croup in children. A coronal neck X-ray revealed a characteristic narrowing of the subglottic trachea, the steeple sign, in all cases. Although flexible laryngoscopy also has a high diagnostic value, it is necessary to pay careful attention to the clinical findings of possible airway obstruction. Two of our three cases and eight of 17 reported cases required airway management, indicating a much more severe condition in adults compared to that in children. Another clinical characteristics of adult cases include that only very severe cases have been diagnosed as croup. A rise of antigen titer against parainfluenza virus type 3 was detected in one case, while influenza virus antigen was detected in the other two cases.

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Arytenoid cartilage dislocation (ACD) is sometimes caused by tracheal intubation or laryngeal injury. A current treatment for ACD is rigid-laryngoscopic closed reduction under general anesthesia. However, hospitalization is usually required for this treatment. Abe (2007) reported fiberscopic baloon reduction under local anesthesia (FBR) for anterior ACD. FBR can be performed repeatedly on outpatients because it is simple and minimally invasive. Our original idea for FBR is using Tiemann catheters (with the curved tip). The insertion procedure into the glottis when FBR is indicated became much easier with the use of a Tiemann catheter, because we can control the position of the tip by turning the axis of the catheter. We report herein on 2 cases of anterior ACD treated with FBR using a Tiemann catheter.

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IgG4-related disease (IgG4-RD) is a novel clinical disease entity characterized by elevated serum IgG4 concentrations, tissue infiltration by IgG4-positive plasma cells and formation of pseudotumor with fibrosis. Occuurence of IgG4-RD has been described in multiple sites, from salivary glands, thyroid gland, pancreas and bile duct retroperitoneum. IgG4-RD with pseudotumor of the larynx is extremely rare, with only 5 cases reported in the literarure until date.
A 62-year-old female patient was admitted to our hospital with a submucosal tumor in the right supraglottic area. Biopsy was performed under general anesthesia twice. The histological findings showed only fibrosis and chronic inflammatory plasma cells. However, the serum IgG4 level was clearly elevated to 1460 mg/dl. In addition, immunohistological staining of the larynx, parotid gland and lymph node confirmed the diagnosis of IgG4-RD. Treatment was started with a high dose of prednisolone (0.6 mg/kg/day) for 2–4 weeks, with tapering of the dose subsequently tapered to 8 mg/day. About 3 days after the initiation of treatment, the pseudotumor of the larynx disappeared completely.
This case is only the sixth report of the association of IgG4-RD with pseudotumor of the larynx. The initial symptom in all patients was hoarseness, and only one gave a history of dyspnea. All the case had been treated with prednisolone and showed improvement of the laryngeal symptoms, except in one case which developed persistent vocal cord immobility.
There is an urgent need for prompt treatment when the larynx is involved, considering the potential for irreversible damage. Long term follow-up and careful check up of whole body are required

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There are several reports showing the effect of a somatostatin analog in postoperative chylous leakage after gastrointestinal surgery and thoracic surgery. We treated a case with a postoperative refractory chylous leakage with a somatostatin analog. The patient was a 63-year-old man. We performed lymph node resection including the venous angle for metastatic cervical lymph node recurrence from tongue cancer. We performed conservative treatment with a ban on food and drink per os, total parenteral nutrition and applied local pressure to the neck chylous leakage. Because the neck chylous leak reached 1321 ml per day, we carried out thoracic duct ligation on the 3rd day after surgery. The chylous leak decreased temporarily after surgery, but increased again to 925 ml per day. Chylous leakage was stopped after the administration of a somatostatin analog for 5 days. We considered that the use of the somatostatin analog in addition to conservative conventional treatment and surgical treatment is one possible strategy to deal with postoperative refractory chylous leakage.

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Castleman’s disease was first reported by Castleman et al. in 1954 as localized large benign hyperplastic mediastinal lymph nodes histologically characterized by hyperplasia of the lymphoid follicles and capillary proliferation with endothelial hyperplasia. We report herein on a rare case of Castleman’s Disease arising in a left parotid gland. A 11-year-old male patient complained of swelling of the left parotid lesion. Preoperative CT scan, MRI and echo findings suggested that the tumor was very hypervascular. As this lesion was clinically suspected to be a benign tumor of the parotid gland, superficial layer segmental resection of parotid gland was performed. After surgery, the tumor was diagnosed as hyaline-vascular type of Castleman’s disease. There is no evidence of recurrence in the patient 40 months after the operation.

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Facial palsy is generally recognized as a symptom of malignancy among parotid tumors. We report herein on multiple Warthin’s tumors involving the parotid and parapharyngeal region accompanied with facial palsy.
A 45-year-old man visited our clinic complaining of right parotid swelling. No other symptom was observed except the swelling. CT revealed multiple tumors involving the right parotid and parapharyngeal region. Fine needle aspiration cytololgy indicated Warthin’s tumor. He did not accept the proposal of surgical removal of the tumor. Six years and eight months later, he had acute onset of right facial palsy and severe pain of the right half of the face. We performed surgery suspecting malignant transformation because of the accompanying facial palsy. The tumors were removed visibly by the cervical and parotid approach with a midline mandibulotomy (i.e.; mandibular push up method). The right facial nerve was preserved because of the lack of malignancy as demonstrated by the intraoperative rapid histopathological diagnosis. The postoperative histopathological examination failed to show malignant transformation of the Warthin’s tumors. No evidence of recurrence of the disease was observed and the facial palsy had almost regressed a year after the surgery.

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We report herein on a case of minocycline-induced black thyroid with papillary thyroid carcinoma. A 60-year-old female, who had taken oral minocycline intermittently for osteomyelitis of the mandible for two years, noticed a palpable thyroid nodule. Fine needle aspiration of the nodule revealed atypical cells and the serum thyroglobulin level was high. Under the diagnosis of suspected thyroid carcinoma, a hemithyroidectomy with central compartment neck dissection was performed. The color of the tumor, which was diagnosed as a papillary carcinoma, was white. On the other hand, the color of the normal thyroid gland was dark red to black with minocycline pigmentation. Minocycline therapy may induce headache, nausea, vomiting, liver dysfunction and dental hyperpigmentation in children. But a minocycline-induced black thyroid is uncommon. Recently, there have been some reports that the risk of malignancy in black thyroid glands is higher than in non-black thyroids.

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Treatment targeting the androgen receptor and HER-2/neu of salivary duct carcinoma has recently attracted attention, however we have encountered a patient who was double negative for androgen receptor and HER-2/neu. The patient was a 78-year-old man. Skin metastasis and cervical lymph node recurrence were noted at six months after surgery. HER-2/neu and the androgen receptor in the surgical specimen were both negative. There was no metastasis at any other site. Irradiation at 50 Gy and of DOC 35 mg/m² every two weeks were administered. The results showed complete response. There have been an only a few reports in which CR with chemoradiation for recurrent salivary gland duct carcinoma has been achieved. In addition, neck recurrence was noted in the present case at 11 months after CR, but showed a good reaction with re-administration of the DOC. Chemoradiotherapy and chemotherapy including taxanes may be an option in treatment of double-negative cases.

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Schwannomas arising from the hypostatic cranial nerve origin occasionally occur in the parapharyngeal space. These are benign tumors caused by proliferation of neoplastic Schwann cells. However, tumor enlargement or surgical procedures may induce paralysis of the nerve of origin. Furthermore, a schwannoma in the parapharyngeal space can cause paralysis of nerves other than the nerves of origin. This event is attributed to the anatomical complexity of the parapharyngeal space.
We report herein on a case of schwannoma of the vagus nerve origin, which caused only hypoglossal nerve paralysis.

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In elderly patients treated with concurrent chemoradiation therapy (CCRT), complications after initiation of therapy, such as delirium, as well as adverse events such as radiation mucositis and granulocytopenia, are considered to affect the subsequent therapy completion rate and treatment effect and may also lead to a poor performance status (PS). Various factors should be taken into consideration prior to the therapy, such as complications, estimated residual function, PS, life expectancy, and the family environment, along with sufficient informed consent. This study evaluated 100 subjects, including 30 elderly patients (age, ≧70 years) and 70 non-elderly patients (age, <70 years) who underwent primary therapy (S-1, nedaplatin with CCRT; SN therapy) for head and neck squamous cell carcinoma in our hospital from January 2005 to August 2011. The following variables were clinically compared between the elderly and non-elderly groups: primary site, staging, response to treatment, therapy completion rate, recurrence rate, adverse events, PS, and complications. In the elderly group, 90% of the patients achieved complete response (CR) while the remaining 10% achieved partial response (PR), giving a response rate of 100%. In the non-elderly group, 87.1% and 12.9% of the patient achieved CR and PR, respectively, again giving a response rate of 100%. The therapy completion rate was 73.3% in the elderly and 90.0% in the non-elderly group, with recurrence rates of 6.7% and 15.7%, respectively. With regard to adverse events, in the elderly group, 73.3% of the patients experienced hematological toxicities of grade 3 or higher, and 50.0% experienced non-hematological toxicities of grade 3 or higher. In the non-elderly group, 57.1% experienced hematological toxicities of grade 3 or higher and 42.9% experienced non-hematological toxicities of grade 3 or higher. Major complications occurring after initiation of therapy were reported in 20.0% of the elderly population and in 5.6% of the non-elderly population. Significant differences between the groups were found in the therapy completion rate, incidence of adverse events, and complications after therapy initiation. These results suggest that CCRT is as effective in the elderly as it is in non-elderly patients, but applying the therapy in the elderly requires careful consideration of pre-treatment care, management of complications during therapy, and post-­treatment rehabilitation.

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When a thyroid nodule has malignant features found by some examinations (e.g. Echo, FNAC, CT), we perform surgical resection. But if the thyroid nodule does not have malignant feature, there is still the possibility of malignancy, especially when the nodule is large. In the case of large pre-operatively benign thyroid nodules, we therefore consider a diagnostic lobectomy. There is, however, no definite recommendation how large a nodule should be before a lobectomy is performed, and how many malignancies exist in pre-operatively benign nodules. In our hospital, we consider surgical resection when the diameter of the thyroid nodule is over 3 cm. In this study, we analyze pre-operatively benign thyroid nodules in which surgical resection was performed in our hospital, how many malignant nodules there were and what the characteristics were between benign or malignant nodule. From 2005 April to 2012 June, 351 patients underwent a lobectomy in our hospital, 70 of which were pre-operatively benign thyroid nodules with diameters of over 3 cm. We analyzed the pathological findings and compared the nodule diameters, serum thyroglobulin, FNAC’s classification and some characteristics of echography between pathologically benign and malignant cases. Fifty-eight patients (83%) had pathologically benign nodules, and 12 patients (17%) had malignant nodules. In 58 benign nodules, 33 nodules (47%) were adenomatous goiter, 24 patients (34%) had follicular adenomas and 1 nodule (1%) was an atypical adenoma. In the 12 malignant patients, 8 patients (11%) had papillary adenocarcinoma and 4 patients (6%) had follicular adenocarcinoma. Almost no significant characteristics were found concerning malignancy, in diameter, serum thyroglobulin, class of FNAC and features of echography. As for complications after surgery, hypothyroidism occured in four patients (6%), and neither hypoparathyroidism nor vocal fold paralysis occurred. We concluded that pre-operatively benign thyroid nodule that were over 3 cm in diameter had about a 17% possibility of malignancy. Examinations may not distinguish whether such pre-operatively benign tumors are benign or malignant before surgical resection. We should therefore consider whether to perform therapeutic surgery or not in such patients.

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