Liquid biopsy has the alternative utility, besides being a diagnostic tool, as a minimally invasive monitoring tool for disease profiling and prognostication. Recently, the incidence of HPV-associated oropharyngeal cancer has been increasing. Also, the choices of chemotherapy, including immune checkpoint inhibitor therapy, has been increasing. A minimally invasive diagnostic tool is desired.

Herein, we demonstrate the usefulness of liquid biopsy, not only for HPV ctDNA monitoring, but also for diagnosis of recurrence, in a patient with HPV-OPC. The ctDNA concentrations decreased and serum HPV-DNA became negative after surgery for the primary tumor. When the patient developed a pulmonary lesion during the follow-up after initial treatment, we initially suspected primary lung cancer clinically. The operated lesion turned out to be a metastatic lesion. The test for HPV-DNA, which had become negative before, had become positive before the pulmonary surgery, suggesting recurrent disease.

Liquid biopsy for monitoring of the ctDNA has the potential to allow the disease status to be monitored in patients with HPV-OPC.

Laryngeal papillomatosis is caused by infection with human papillomavirus (HPV) type 6 and/or 11. Laryngeal papillomatosis recurs frequently, and malignant transformation occurs in 1.6%-4% of the cases. Surgery is the treatment of first choice. While adjuvant therapies such as interferon, Chinese medicines, proton pump inhibitors, indole 3 carbinol, cidofovir and vaccines have been tried, none has come to be positioned as the standard of care.

We report seven patients with laryngeal papillomatosis who underwent multiple surgeries. All were men. The surgery was performed in combination with two or three of the following: use of an electric scalpel, CO₂ laser, YAG laser, sharp resection, and intralesional injection of cidofovir. Intralesional injection of cidofovir after resection was performed in four cases, and remission was achieved in three of these cases. Cidofovir is an unapproved drug in Japan and is not yet approved for use in cases of laryngeal papillomatosis in other countries. However, the outcomes in our cases and other reports suggest that intralesional injection of cidofovir is effective.

HPV6 (n=5), HPV11 (n=1) and HPV negative (n=1) detected respectively. Malignant transformation occurred in one case and HPV negative. Moreover, p16 immunohistochemistry was performed in all cases. However, no relation with number of operations and HPV status was found.

The life cycle of HPV in laryngeal papillomatosis is largely unknown, and there is no consensus on methods of treatment other than surgery. More research is needed to elucidate the life cycle of HPV and the pathophysiology of laryngeal papillomatosis.

Congenital cholesteatoma in the tympanic cavity can be divided into two types - the closed-type cholesteatoma, which takes the form of a keratotic cyst, and the open-type cholesteatoma, characterized by a flat surface of the epidermis on the middle ear mucosa. Closed-type cholesteatoma is usually identified as a globular white mass through a normal tympanic membrane; whereas the tympanic membrane appears normal in open-type cholesteatomas. Therefore, it is difficult to diagnose open-type cholesteatomas, which are often identified accidentally during exploratory tympanotomy for preoperative diagnoses such as conductive hearing loss. Herein, we report a case of open-type cholesteatoma, in which the diagnosis was suspected from the findings of diffusion-weighted MRI examination using the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) technique.

An 18-year-old male presented to our hospital with the complaint of right hearing loss, which was suspected at a previous ENT clinic to be caused by a congenital ossicular anomaly. Otoscopic examination failed to reveal any abnormalities. Pure-tone audiometry showed moderate conductive hearing loss in the right ear. Computed tomography of the temporal bone revealed a defect of the long process of the incus and superstructure of the stapes, with a surrounding shadow that appeared to be soft tissue. On the basis of these findings, we suspected an open-type cholesteatoma with a defect of the ossicles. Diffusion-weighted MRI examination using the PROPELLER technique showed a high-intensity in the temporal bone, suggestive of a cholesteatoma. We performed exploratory tympanotomy, and found the open-type cholesteatoma in the middle ear. The cholesteatoma was removed without ossiculoplasty, and until now, nine months after the surgery, there has been no sign of recurrence.

Our case showed the usefulness of diffusion-weighted MRI using the PROPELLER technique for the diagnosis of the open-type cholesteatoma. The possibility of open-type cholesteatoma should be borne in mind in patients diagnosed preoperatively as having a congenital ossicular anomaly, and diffusion-weighted MRI with the PROPELLER technique is indicated in such patients towards confirming the diagnosis.

Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm that secretes fibroblast growth factor 23 (FGF23), which suppresses re-absorption of phosphorus in the renal tubules and leads to chronic hypophosphatemia, thereby resulting in tumor-induced osteomalacia (TIO). Herein, we report a patient who had suffered multiple fractures and was diagnosed as having PMT in his left temporal bone two years later the appearance of the first symptom. For his first consultation at our department, the patient was transported to the hospital on a stretcher, as he had found it difficult to turn over in bed due to generalized bone pain and multiple pathological fractures. Examination revealed that the tumor had already spread deep into the skull base; therefore, considering the general condition of the patient, we determined that radical surgery would be difficult. Transmastoid surgical debulking was performed three months after the first consultation at our department, and the patient’s quality of life improved after the surgery. However, 10 months after the surgical debulking procedure, since we did not observe any improvements in his clinical findings, we performed radical surgery together with the neurosurgeons, which yielded good results. This case suggests that radical surgery is essential for the treatment of PMT. Even in cases where radical surgery is initially deemed to be challenging, gradual steps towards radical surgical treatment may be possible.

Intratympanic gentamicin is used to control episodic vertigo in patients with the severe form of Meniere’s disease, but it may also cause hearing loss. The purpose of this study was to investigate gentamicin-induced changes in hearing in such patients.

In this study, a total of 38 patients (mean age 55.4 y, range 23–86 y, male 16, female 22, side rt 17, lt 21) who received intratympanic gentamicin administration were monitored by pure-tone audiogram (PTA) and click-evoked extratympanic electrocochleography (ECoG) over a period of five years. Hearing detection thresholds were measured by PTA, and the summating potential (SP), action potential (AP) and SP/AP ratio were determined by ECoG. The patients received dilute gentamicin solution with sodium bicarbonate administration into the middle ear 1 or 2 times.

The mean hearing level at mid frequencies (500–2000 Hz) was 47 dB before the treatment and 40 dB after the treatment. The mean hearing gains at the frequencies of 125, 250, 500 Hz, and 1 kHz were 12.6, 12.1, 10.5, and 6.2 dB, respectively. The differences in the hearing levels at the frequencies of 125, 250, and 500 Hz recorded before and after treatment were statistically significant (p<0.001).

The longitudinal follow-up conducted after the treatment did not show any worsening of the hearing levels or relapse of the vestibular symptoms. The SP/AP ratio (0.49 before and 0.34 after treatment) seemed to return to normal in the long term after gentamicin treatment. Normalized SP/AP resulted in hearing gain at the frequencies of 250 and 500 Hz. The amplitudes of the SP (0.59 before and 0.3 after treatment), and especially of the AP (1.23 before and 0.86 after treatment), decreased after gentamicin treatment, indicating hearing loss. The hearing was better in 16 cases (42%) and showed no change in 18 cases (47%), while hearing loss occurred in 4 cases (11%) because of gentamicin.

Intratympanic gentamicin treatment alleviated hearing loss and reduced vertigo. It also normalized the SP/AP ratio, and the consequent hearing gain may reflect a reduction in endolymphatic hydrops. Long-term observation after gentamicin treatment revealed stable hearing.

Unilateral paranasal disease is often encountered at otorhinolaryngology outpatient clinics. CT is the most commonly used modality to differentiate malignant tumors from inflammatory diseases in cases with unilateral paranasal disease. Paranasal malignancies are characterized by bone destruction. In unilateral paranasal disease without any evidence bone destruction, it may be difficult to differentiate inflammatory diseases from malignancy. The purpose of this study was to examine the differences between the clinical and histopathological diagnoses in patients with unilateral and bilateral paranasal diseases diagnosed by radiological examinations. Preliminary diagnoses made on the basis of clinical observations and CT findings were compared with the final histopathological diagnoses made from the resected specimens and the reasons for inconsistencies are discussed. We focused on154 cases that were diagnosed as having paranasal disease by CT. The patients were treated by surgery and the resected specimens were processed for histopathological diagnosis. The 154 operated patients comprised 68 patients with unilateral disease and 86 patients with bilateral disease. In the unilateral paranasal disease group, we confirmed chronic sinusitis in 30 cases (44.1%), postoperative maxillary cyst (POMC) in 5 cases (7.4%), maxillary mycosis in 4 cases (5.9%), allergic sinusitis in 5 cases (7.4%), maxillary sinusitis of dental origin in 2 cases (2.9%), inverted papilloma in 11 cases (16.2%), hemangioma in 5 cases (7.4%), malignant lymphoma in 2 cases (2.9%), and maxillary cancer in 4 cases (5.9%). On the other hand, in the bilateral paranasal disease group, the diagnoses were chronic sinusitis in 72 cases (83.7%), allergic sinusitis in 12 cases (14%), inverted papilloma in 1 case (1.2%), and POMX in 1 case (1.2%). In 56% of cases with a preoperative diagnosis of chronic sinusitis in unilateral paranasal disease, the histopathological diagnosis differed; in particular, in 8.8% of these cases, the diagnosis was malignancy. Additional diagnostic examinations to get more information, such as MRI, cytological examinations, or even open biopsy, should be performed before surgery in patients with unilateral paranasal disease when malignancy is suspected. Early identification of paranasal disease avoids delay in surgical intervention.

Neck cystic masses of various causes are frequently encountered in otorhinolaryngological practice. Papillary thyroid carcinoma is also known to be associated with cystic cervical lymph node metastasis. Measurement of the thyroglobulin level in the cyst fluid is considered to be useful for the diagnosis. Herein, we report a case of cervical schwannoma that was initially suspected as a cystic lymph node metastasis secondary to a papillary thyroid carcinoma. A 49-year-old woman was diagnosed as having thyroid papillary carcinoma and cervical lymph node metastases. She was treated by total thyroidectomy and cervical lymph node resection. Three years after the operation, she developed a cystic mass in the upper left neck, which began to gradually increase in size. We resected this cystic mass in the upper neck under the suspicion that it was a cystic lymph node metastasis secondary to the papillary thyroid carcinoma, but histopathology of the resected specimen revealed the diagnosis of schwannoma.

Autosomal dominant non-syndromic hearing loss (ADNSHL) is genetically and clinically heterogeneous. To date, 48 causative genes have been identified. Of these genes, TECTA, WFS1 or KCNQ4 mutations are the most frequently identified in subjects with ADNSHL in Japan. We performed mutation analysis of TECTA, WFS1 and KCNQ4 in a Japanese family with ADNSHL, and identified a heterozygous missense mutation in TECTA. The missense mutation was located in the zonadhesin domain in the alpha-tectorin protein encoded by the gene. The affected family members, including 6-year-old girl, 59-year-old grandmother and 33-year-old father, showed bilateral moderate to severe sensorineural hearing loss. Their audiogram patterns were of the symmetric and descending type. The average annual threshold deterioration of the girl was 0.5 dB/year and that of her father was 0.5 dB/year, indicating that their hearing loss was stable. Their auditory findings were consistent with the established genotype-phenotype correlation of missense mutations in TECTA: missense mutations in the zonadhesin domain cause high-frequency hearing loss; when amino acid residues other than cysteine are affected, the hearing loss is stable.

Olfactory neuroblastoma is a rare malignant tumor arising from the olfactory part of the nasal cavity. These tumors often grow to large sizes before causing any symptoms. By the time a patient presents to an otorhinolaryngological clinic with any symptoms such as epistaxis and nasal congestion, the tumor may have extended to the base of the skull. We report a case of an olfactory neuroblastoma of the nasal cavity. A 40-year-old woman was admitted to our department with an intranasal mass diagnosed by head MRI. The tumor was confined to the nasal cavity and was removed by nasal sinus endoscopic surgery. Histopathological and immunohistochemical examination of the resected specimen revealed the diagnosis of olfactory neuroblastoma originating in the nasal cavity. Follow-up after resection of the tumor by surgery has not revealed any evidence of recurrence until date.

Cartilage conduction (CC) was reported in 2004 as a third pathway for sound transmission, besides air conduction (AC) and bone conduction (BC). As compared to BC, CC does not require strong and sustained attachment on the skin; cartilage is much lighter than the skull bone, so that less vibrational power is needed to trigger CC. Therefore, CC hearing aids are small and lightweight, and may be of particular benefit for patients with external ear disorders. To date, 25 patients have received a trial of CC hearing aids at our hospital. Herein, we report 3 cases who opted to purchase CC hearing aids after the trial. Case 1 was 16-year-old female patient with bilateral bony aural atresia. She had used BC hearing aids since the age of 6 months. Her parents worried about skull bone deformation arising from her wearing of BC hearing aids. After the trial, she was satisfied with the light-weight characteristic and fitting comfort of CC hearing aids. Case 2 was a 10-year-old girl with right bony aural atresia. She had not used any hearing aids until this trial. After the trial, she could identify the location of passing cars on the way to school by binaural. Case 3 was a 76-year-old female. She had suffered from conductive hearing loss in the right ear ever since she underwent surgery for carcinoma of the right external auditory canal. After the trial, she found it easy to understand conversations in her business life. Thus, not only patients with congenital bilateral external ear atresia, but also those with unilateral atresia or other conductive hearing loss can benefit greatly from CC hearing aids.

Spindle cell carcinoma is a malignant tumor with a mixture of squamous cell carcinoma and sarcoma-like components, mainly spindle cells. It is considered to be a malignant tumor that occurs at a relatively low incidence in the head and neck region. We encountered eight cases of spindle cell carcinoma in the head and neck region, and present a report of these cases, with a discussion of the literature.

The eight cases included one case in the oral cavity, two cases in the sinuses, one case in the epipharynx, one case in the mesopharynx, two cases in the hypopharynx, and one case in the larynx. The masses appeared as polyp-like raised lesions in seven cases. Two patients had undergone radiation therapy. One patient was more than 50 years old and another was 2 years old. Biopsy was performed once in four patients and multiple times in four patients, and the diagnosis of spindle cell carcinoma had been made prior to the surgery in six patients.

Because spindle cell carcinoma is generally considered to be radioresistant, we selected surgery as the treatment modality in seven patients. One patient was found to have a positive stump on histopathological examination of the resected specimen, and received further chemoradiotherapy. Five patients were disease-free, and three died of the primary disease within one year. Therefore, the prognosis of spindle cell carcinoma was considered to be worse than that of squamous cell carcinoma. Favorable prognostic factors were early stage, polyp-like appearance, location in the glottis, and shallow sarcoma lesions. The poor prognostic factors were radiation therapy. We could not confirm this as a prognostic factor, although we considered it in the analysis.

Behcet’s disease is a chronic relapsing systemic inflammatory disease with four characteristic symptoms, including oral aphthous ulcers. In general, oral aphthous ulcers in Behcet’s disease are often confined to the oral cavity, but there have been reports of cases in which the aphthous ulcers have extended to the pharynx and larynx. Because there are no specific laboratory findings for the diagnosis of this disease, it is often difficult to diagnose. Herein, we report four cases of Behcet’s disease with intractable aphthous ulcers in the pharynx and larynx, including the epiglottis.

Herein, we report a rare case of esophageal perforation caused by a large wing-shaped fishbone. The patient was a female in her forties with mental retardation who presented with a sore throat, fever, and dysphagia and gave a history of having eaten yellowtail fish seven days before. Flexible fiberoptic laryngoscopy revealed a large fishbone emerging from the left piriform sinus and stuck in the cervical esophagus. Cervical computed tomography (CT) revealed a cervical esophageal perforation and blood tests revealed elevation of acute inflammatory markers. The fishbone, which was approximately 4 cm in length, was removed by the transcervical approach, and the esophageal perforation was closed by primary suture. The patient received intravenous antibiotics to prevent abscess formation, could resume oral intake on postoperative day 7, and was discharged from the hospital 14 days after the surgery without any complications. Fishbone ingestion can cause significant complications, including perforation of the esophagus. It is essential to promptly identify a foreign body in the cervical esophagus by CT and remove it immediately by the transcervical approach, which can be lifesaving and is usually associated with only minor postoperative complications.

Pharyngocutaneous fistula (PCF) is the most common complication following total laryngectomy. To establish the incidence of this complication and to determine the predisposing factors, we conducted this retrospective study in a cohort of 106 patients who had undergone total laryngectomy between January 2007 and April 2019. The following factors were analyzed for their potential correlations with the risk of occurrence of PCF: patient background, tumor characteristics, comorbidities, and nutritional status. Eighteen patients developed PCF (overall incidence, 17%). According to the results of univariate analysis, the rate of fistula formation was significantly higher in patients who had undergone salvage surgery, had low preoperative blood hemoglobin and prealbumin levels, and/or had hepatic cirrhosis (p<0.05). The analysis also identified the nutritional status of the patient as an important determinant of the risk of PCF formation. Thus, maintenance of a normal perioperative nutritional status should be ensured in the patients to prevent the formation of PCF.

The incidence of human papillomavirus (HPV)-related oropharyngeal cancers has been increasing in recent years. However, the mechanisms of viral transmission, carcinogenesis and natural history of these cancers are not yet well understood. Herein, we describe the case of a non-smoking married couple who presented with HPV-positive oropharyngeal squamous cell carcinoma within six months of each other. Tumor biopsies were positive for p16 and both had the same high-risk HPV genotype (HPV type16). The wife underwent transoral tonsil resection with bilateral neck dissection following adjuvant chemoradiation, and the husband received chemoradiation. Neither patient has shown any evidence of recurrent disease until now, four years since the treatment completion. Although the prevalence of HPV-related oropharyngeal cancer has increased, as also awareness about this disease, there are still few couples with the disease, not only indicating that the development of oropharyngeal cancer following HPV transmission between couples is a rare event, but also indicating there is the potentially infectious nature of oropharyngeal cancer still unknown.

Superselective Intra-arterial Cisplatin Infusion and Concomitant Radiotherapy (RADPLAT) is adopted at multiple centers as treatment for advanced maxillary sinus cancer, and favorable results have been reported. We examined the treatment results and adverse effects of RADPLAT at our hospital. From January 2004 to February 2019, we examined the data of 58 patients with maxillary sinus cancer who underwent RADPLAT. Of the 58 patients, 48 were male, 10 were female, the median age was 68 years (38-87 years), and the histopathological diagnosis was squamous cell carcinoma in 56 cases and transitional cell carcinoma and undifferentiated carcinoma in 1 case each. The criteria for treatment completion were as follows: six cycles of CDDP administered at 100 to 120 mg/m² weekly, with irradiation at 60 to 70 Gy. The treatment was completed in 84.5% of cases (49/58 cases), and in the group in which the treatment was completed, the response rate (CR or PR) was 98%, the 5-year local control rate was 69.1%, and the 5-year crude survival rate was 71. 8%. The serious adverse events were blindness in 5 cases (of which 4 had received intra-arterial injection into the ophthalmic artery) and cerebral infarction in 2 cases, while no sequelae were observed after conservative treatment. There were no cases with severe renal impairment. The high response rate, 5-year local control rate and 5-year crude survival rate were consistent with previously reported treatment results. As compared to systemic chemotherapy, there were fewer adverse events, and this treatment may be particularly indicated for elderly patients and mild renal impairment. However, it is necessary to carefully consider the indication of treatment, provide information to the patients and their families about this treatment, including the risks, and obtain their informed consent.

Osseous choristoma is an extremely rare benign lesion characterized by ectopic bone formation in the soft tissue of the head and neck region. We report two cases of osseous choristoma occurring at the base of the tongue.

Case 1 was a 17-year-old woman who was referred to our hospital with an asymptomatic pedunculate mass in the tongue; she had first noticed the mass approximately eight years prior to her admission. Case 2 was a 68-year-old man referred to our hospital with the complaint of discomfort in the throat. Fiberoptic laryngoscopic examination revealed a pedunculated and smooth mass measuring approximately 10 mm in diameter on the left side of the cecal foramen of the tongue in both cases. We performed transoral surgical excision of the lesion at the clinic, and microscopic examination of the specimen revealed the lesion as being composed of lamellated bone and covered with normal epithelium. The histopathological diagnosis was osseous choristoma in both cases.

In this report, we review 22 cases of osseous choristoma reported in the literature since 2001 and discuss their clinical findings.

We report a rare case of a patient with a skull base metastasis secondary to hepatocellular carcinoma, who presented with visual impairment as the initial presenting symptom.

A 64-year-old male patient with no symptoms and no history of viral hepatitis was diagnosed as having liver and skull base tumors after being detected, during a medical examination, as having a lung tumor. A few weeks later, he became blind, but there were no ocular motility disorders. Examination revealed a tumor causing bone destruction in the sphenoid sinus, orbital tip and middle skull base, and PET-CT revealed FDG accumulation in the same area. We performed a biopsy of the sphenoid sinus lesion under endoscopic guidance, without any major bleeding, and histopathology revealed a metastatic hepatocellular carcinoma. The patient was treated by TACE, performed twice, for the liver lesions and radiation therapy for the skull base lesions, followed by oral sorafenib treatment for 8 months. Sorafenib was then switched to regorafenib because of PD. Subsequently, we switched the drug to lenvatinib and then ramucirumab, and administered additional stereotactic radiation therapy (SRT) because of visual impairment on the opposite side, but the patient died 3 years 7 months later of uncontrollable rectal bleeding. We think that the skull base metastases occurred in the bone, and not in the cavernous sinus, because the patient had only visual impairment not associated with any ocular motility disorder, disappeared as a first symptoms. Although molecular-targeted drugs that have emerged as treatments for hepatocellular carcinoma have been demonstrated to prolong the survival, radiation therapy is used as local therapy to maintain the QOL in patients with skull base lesions.

Schwannoma is a slow-growing, benign tumor of the peripheral nerves arising from the Schwann cells. We report a rare case of a schwannoma originating from the submandibular branch of the lingual nerve. A 26-year-old man presented with a painless right submandibular swelling, and CT revealed a 4.5-cm tumor arising from the right submandibular gland. Despite the tumor being so large, ultrasonography-guided fine-needle aspiration cytology (FNAC) failed to provide a definitive diagnosis. Adhesion of the tumor to the lingual nerve was noted during resection of the tumor along with the submandibular gland. Microscopic examination revealed a well-encapsulated tumor composed of spindle-shaped cells in a palisading arrangement. We concluded that the tumor was a schwannoma arising from the submandibular ganglion. Paralysis of the marginal mandibular branch of the facial nerve developed as a postoperative complication, although the patient recovered from this complication by 3 months after the surgery. There was no evidence of lingual nerve paralysis.

The lack of specific symptoms sometimes makes it difficult to make an accurate preoperative diagnosis of schwannoma. Even MRI fails to distinguish between schwannoma and pleomorphic adenoma, which is the most commonly occurring tumor of the submandibular gland, and FNAC also often fails to yield the diagnosis. We review nine cases of schwannoma arising from the lingual nerve or the submandibular ganglion and discuss their clinical findings.

We encountered the case of an infant aged 5 months with autoimmune neutropenia (AIN) who presented with a parotid abscess caused by methicillin-resistant Staphylococcus aureus (MRSA). The infant improved early with puncture drainage of the external ear canal and antibacterial treatment with vancomycin (VCM). However, it was difficult to reach the proper dosage of VCM.

AIN is one of the chronic neutropenias of infancy and early childhood. It is primarily characterized by increased destruction of neutrophils by antineutrophil antibodies. It has been estimated to occur at a frequency of 1 in 100,000, but the number of cases diagnosed as having this condition appears to be increasing with the recent progress in techniques for measurement of antineutrophil antibodies. The infants present with recurrent mild bacterial infections, but the condition becomes less severe with an increase in the neutrophil count in almost every case by the age of five.

We report two cases in which drooling was reduced by percutaneous use of scopolamine ointment. Case 1: A 75-year-old female patient with amyotrophic lateral sclerosis (ALS). In addition to low-pressure continuous suction of the mouth, she was started on scopolamine ointment applied over the postauricular region. Before the ointment was prescribed, the volume of continuous suction was 400 ml/day, whereas it decreased to 150 ml on day 1 and to 200 ml on day 2 after the start of ointment application. Case 2: A 17-year-old female patient with cerebral palsy. If the score on Numeric rating scale (NRS) for the caregiver’s burden before the start of ointment application was 10, the score decreased to 2–4 after 4 hours and 1–3 after 24 hours of ointment application. Two and a half days after the ointment application, there was an objective increase in the amount of saliva, so that the application interval was shortened from every 3 days to every other day. Thereafter, there was a consistent decrease in the amount of saliva. Scopolamine is known to have side effects such as dryness of the mouth, drowsiness, blurred vision and mydriasis, constipation, and urinary retention. However, even after several months of use, no side effects have been observed in either case. We present some review of the literature, including on instructions for preparing and using scopolamine ointment.

MALT lymphoma is a low-grade B-cell lymphoma. Although it can develop in any organ, laryngeal MALT lymphoma is extremely rare, and is reported to account for less than 1% of all laryngeal malignancies. An 80-year-old woman was admitted to our hospital after she was diagnosed as having a subglottic mass by a neighborhood doctor whom she consulted because of a few months’ history of hoarseness of voice. She underwent laryngeal microsurgery, and was referred to the hematology department because histopathology led to the laryngeal MALT lymphoma. Treatment was considered, but then, in consideration of her age, etc., it was decided to follow her up at the outpatient department. One and a half years after the operation, the subglottic mass had disappeared spontaneously, and it was considered as a case of spontaneous disappearance of a laryngeal MALT lymphoma.

Adenomatous goiter is a benign disease, and grows slowly. Some thyroid carcinomas have been reported to cause airway stenosis and choking, however, airway stenosis and choking caused by a benign thyroid tumor is rare. We report the case of a patient with adenomatous goiter who died of airway obstruction caused by the goiter. The patient was a 79-year-old woman who was referred to our hospital with a neck tumor. Ultrasonography revealed multiple thyroid tumors measuring approximately 10 mm each in diameter, in both the lobes of the thyroid. We performed fine-needle aspiration cytology, and the cytological diagnosis was adenomatous goiter, with no evidence of malignancy. The mass gradually grew bigger, but additional aspiration cytology yielded the same results. We discuss airway stenosis caused by adenomatous goiter, along with a review of the literature.

Actinomycosis is a systemic chronic bacterial infection caused by Actinomyces israelii, an anaerobic organism normally resident in the human mouth. It can involve any organ, but cervicofacial disease is the most common. On the other hand, in the field of otorhinolaryngology, fungal infection is usually detected in the ears, nasal sinuses, mouth, or pharynx, and the most common causative organisms are Aspergillus or Candida species. Involvement of the larynx, not only by actinomyces infection, but also by any fungal infection, is relatively rare. Herein, we present a case of co-infection with Actinomyces and Aspergillus in a 67-year-old male patient. The patient had a number of risk factors, including myelodysplastic syndrome, organizing pneumonia, old myocardial infarction, heart failure, heavy smoking, and oral steroid therapy. He presented with the complaints of sore throat and hoarseness after he got the ful. We recognized redness around the vocal cords at the first visit, and initiated the patient on treatment with acyclovir under the suspicion of varicella zoster virus infection. Although the condition seemed to improve initially, sulfur granules and thick white material eventually appeared in the larynx. Histopathological examination confirmed the diagnosis of actinomycosis and aspergillosis. The patient improved with penicillin plus antifungal drug therapy.

Epistaxis is a clinically important symptom. All doctors are required to know how to provide appropriate treatment for epistaxis. We report on the results of epidemiologic studies and factors identified as affecting the risk of rebleeding in patients with epistaxis at our hospital. The subjects were 352 patients (221 males, 131 females) who visited the Otolaryngology outpatient department of Hamamatsu University Hospital with the chief complaints of epistaxis during the 5-year period from January 1, 2014, to December 31, 2018. The most commonly encountered were cases with idiopathic epistaxis. In regard to relationships of the age, sex, antiplatelet/anticoagulant drug therapy, bleeding site, blood pressure, presence of allergic rhinitis, etc., with the risk of rebleeding, there was a significant association between the site of bleeding (especially high risk in cases with posterior bleeding and bleeding from the middle turbinate and middle nasal passages) and the risk of rebleeding (P <0.01).

Recently, an increasing number of cases of congenital cholesteatoma in children have been reported. Surgery is the most frequently selected treatment for acute cases, in which rapid enlargement of the lesion is accelerated by infection and inflammation. However, spontaneous regression of congenital cholesteatomas has also been reported. Herein, we present two cases of spontaneous regression of congenital cholesteatoma and compare the outcomes in these patients to the outcomes reported previously for similar cases. We suggest that a careful observation period of between half year and a year before the decision to perform surgery would be beneficial for children under the age of 4 years classified as having Potsic Stage I or II disease.

We present a rare case of methotrexate-associated lymphoproliferative disorder (MTX-LPD) involving the paranasal sinuses, orbits, and pituitary gland. A 65-year-old-woman was admitted to our hospital with ptosis, double vision, headache, and multiple subcutaneous nodules. She had received MTX for 10 years as treatment for rheumatoid arthritis. Computed tomography showed multiple masses in the paranasal sinuses, orbits, mediastinum, lungs, kidneys, and subcutaneous tissue. Magnetic resonance imaging revealed a mass in the sella. Endocrine examination revealed hypopituitarism and central diabetes insipidus. Biopsy of the lesions from the upper turbinates, paranasal sinuses, mediastinum, and subcutaneous nodules led to the diagnosis of MTX-LPD. MTX was discontinued, and methylprednisolone was administered to treat the oculomotor nerve palsy. Repeat imaging after two weeks showed marked resolution of all the lesions. Until now, 3 years since MTX was discontinued, there has been no evidence of recurrence of the lesions.

Laryngomicrosurgery is a well-established surgical procedure that is widely performed in general hospitals, but it is often performed by inexperienced doctors. The teeth (mainly the incisor tooth) or the gingiva may be damaged during insertion or fixation of the laryngoscope by an inexperienced operator, which could lead to medical litigation. Therefore, it is important, from the point of view of medical safety, to provide some kind of protection for the teeth. At our department, a prosthesis made of an elastic impression material called Coltoflax^®, which is mainly composed of polysiloxane, is fitted over the dental arch of the patient just before the operation field deployment, to protect the teeth. Since this method is simple and the prosthesis can be made into any shape, it is useful not only for protecting the teeth, but also for fixing the laryngoscope. In addition, this method appears to be particularly useful in institutions where no facilities exist for dental or oral surgery.

Small bowel perforation caused by metastasis from head and neck carcinomas is rare. We report a case of oropharyngeal carcinoma with metastasis to the small bowel.

A 64-year-old woman who had received radiotherapy for oropharyngeal carcinoma presented to us complaining of abdominal pain. CT revealed free air in the abdomen, and emergency surgery was performed. During explorative laparotomy, many tumors were detected in the mesentery; one of them had caused a free perforation and another had caused stricture of the small bowel. The tumors were resected, and the postoperative diagnosis was metastatic squamous cell carcinoma (p16 positive). The patient could eventually resume oral intake and was discharged from the hospital. However, 27 days after the operation, she presented again with abdominal pain. CT showed free air, and there was evidence of panperitonitis. She died 4 hours later.

Small bowel metastasis accounts for less than 10% of malignant tumors of the small bowel, and metastases to the small bowel secondary to head and neck SCC are very rare. Furthermore, they are rarely symptomatic and carry a very poor prognosis. Bowel perforation by metastasis is thought to occur in the terminal stages of cancer.

The symptoms of cerebrospinal otorrhea resemble those of otitis media with effusion. Doctors sometimes mistakenly treat cerebrospinal otorrhea as otitis media with effusion. We report a case of cerebrospinal otorrhea that was diagnosed in a patient who presented with a mistaken diagnosis of persistent otitis media. A 59-year-old woman with water-like otorrhea from her left ear visited our hospital to check for cerebrospinal fluid leakage. The first doctor to examine her considered that the fluid drainage was from the middle ear. However, despite two myringotomies and also insertion of a ventilation tube, the otorrhea persisted. While the otorrhea had temporarily stopped at her first visit to our hospital, CT revealed several bony defects of the skull base and a mass in the left attic. Subsequent MRI showed a meningocele-like signal in the left temporal bone. She was referred to a neurosurgeon and underwent skull base surgery. Since several bony defects were revealed at the skull base in the left temporal bone, a trans middle fossa approach was chosen for the surgery. The middle ear fluid disappeared and her hearing recovered after the surgery.

All penetrating neck wounds are potentially dangerous and require emergency treatment, because there are important vessels, nerves, and organs in the neck. We report the rare case of a 71-year-old man with neck injury caused by a glass fragment that penetrated into the floor of the mouth from the submandibular region. The patient had accidentally fallen through a glass door and sustained a 15-cm long incised wound in his neck. He was initially transferred to a district hospital, where he was diagnosed as having arterial bleeding and a neck injury penetrating into the oral cavity; ENT surgeons at the hospital performed temporary hemostasis and tracheotomy under local anesthesia, and the patient was urgently transported to our hospital by ambulance. On admission, he was conscious, and his general condition was good. CT showed no damage to the major vessels, but revealed free air around the sublingual region. Therefore, emergency surgery was performed to repair the perforation from the neck into the oral cavity under general anesthesia. We found the facial artery and facial vein and ligated them during the operation, and the opening into the oral cavity was closed with absorbable sutures. The postoperative course was good, the patient resumed oral intake on day 4 after the surgery, and he was discharged from the hospital on day 9 after the surgery, with the only postoperative complication of palsy of the marginal mandibular branch of the facial nerve. In this report, we review nine cases of neck injury penetrating into the floor of the mouth and 11 cases of neck injury caused by a glass fragment reported in the literature and discuss their clinical findings.

HPV-related multiphenotypic sinonasal carcinoma (HMSC) is a recently proposed disease category of human papillomavirus-associated sinonasal carcinoma. The clinical prognosis is relatively good, even though the histopathological features suggest a high-grade malignant tumor. In this paper, we report a case of HMSC. A female patient in her 30s presented with a history of nasal obstruction and nasal bleeding. A tumor was detected in the right nasal cavity, which was diagnosed by biopsy as myoepithelial carcinoma. Histopathological examination of the resected specimen confirmed the diagnosis of HMSC, however, there has been no evidence of local recurrence or distant metastasis detected until date. Distant metastasis could occur many years after the initial diagnosis, so that careful long-term follow-up of these patients is important.

Subjects with superior semicircular canal dehiscence syndrome (SCDS) show various characteristic symptoms, including hyperacusis, autophony, and pressure-induced vertigo. SCDS should be differentiated from patulous Eustachian tube (PET), since the auditory symptoms of the two conditions could be similar. Herein, we report a case of SCDS who had been misdiagnosed as having PET at a previous ENT clinic. A 46-year-old male patient was referred to our hospital from an ENT clinic, as he had not responded satisfactorily to treatment for PET. While he showed symptoms that could be consistent with the diagnosis of PET, sonotubometry and tubo-tympano-aerodynamic-graphy failed to reveal any characteristic objective features of PET. High-resolution computed tomography of the temporal bone revealed dehiscence of the superior semicircular canal in both ears. The thresholds of the cervical vestibular evoked myogenic potential response were lower than the normative level in both ears. On the basis of these findings, we diagnosed the patient as having SCDS, although we could not elicit Valsalva maneuver-induced eye movements or nystagmus. We performed round window reinforcement, since the patient did not improve with conservative treatments. The symptoms improved after the operation, and there has been no evidence of recurrence.

The endoscopic Denker’s approach and the Caldwell-Luc approach (CL approach) are useful approaches that allow broad access to the maxillary sinus, especially, to lesions present in the anterior wall of the maxillary sinus. However, these techniques have their own inherent obstacles; for example, the endoscopic Denker’s approach requires removal of the piriform aperture, and the CL approach needs a sublabial incision. Recently, a new approach called “direct approach to the anterior and lateral part of the maxillary sinus with an endoscope (DALMA)” was reported by Omura et al. The DALMA method allows endoscopic access to the anterior wall of the maxillary sinus without the need for a sublabial incision or removal of the piriform aperture. We report a case of recurrent inverted papilloma of the maxillary sinus that could not be resected by endoscopic modified medial maxillectomy (EMMM), but was resected using DALMA. DALMA is an effective and minimally invasive method that can be used as an alternative to the CL approach.

Herein, we report the case of a patient who required frequent external neck incisions for refractory deep neck abscesses associated with hyper-IgE syndrome. A 34-year-old female patient with a history of hyper-IgE syndrome presented to our hospital complaining of fever, sore throat, and swelling of the right side of the neck. Once the diagnosis of deep neck abscesses was made by computed tomography, treatment with meropenem was initiated; however, on day 5, exacerbation of pharyngeal edema and progression of the abscesses were observed, and we performed the first external neck incision and drainage. On day 7, a prolonged inflammatory reaction was noted, and the antimicrobial agent was changed to cefepime and vancomycin (VCM). Thereafter, the inflammatory reaction improved; however, on day 30, enlargement and progression of the abscesses toward the mediastinum were observed, and we performed the second external neck incision and drainage. Mediastinotomy was also performed in collaboration with the department of thoracic surgery. Culture of the abscess fluid grew methicillin-resistant Staphylococcus aureus, so that treatment with VCM was resumed. On day 34, progression of the abscesses toward the anterior aspects of both the trapezius muscles was observed, and we performed the third external neck incision and drainage. The antimicrobial agent was then switched to linezolid, after which irrigation was initiated from the drainage tube. This resulted in normalization of the serum C-reactive protein level on day 75, and the patient was discharged on day 95. This was a patient with refractory deep neck abscesses due to decreased autoimmune capacity resulting from primary immunodeficiency. Immunodeficient patients require intensive treatment from the early stage of infection. Moreover, decisions need to be promptly made regarding the timing and method of external neck incision and the selection and switching of antimicrobial agents.

Schwannomas are rare benign tumors that arise from the neurolemmocytes. Among cases of schwannoma that arise from nerves, vagal nerve schwannoma is the most common in the head and neck region. Surgical resection is the treatment of choice. Postoperative complications such as hoarseness and dysphagia can affect the patients’ quality of life, so that attempts at nerve preservation should be made whenever possible.

A 46-year-old female patient underwent resection of a vagal schwannoma under continuous intraoperative neuromonitoring (CIONM) that allows real-time intraoperative feedback. The recurrent laryngeal and vagal nerve activities were monitored using an electromyographic endotracheal tube. We also used Narrow Band Imaging (NBI) to detect the tumor capsule and performed intracapsular excision of the tumor. She had no postoperative complications. In conjunction with NBI, CIONM allows for successful preservation of the vagal nerve and a reduced risk of postoperative complications.

Angioedema refers to edema of the deep dermis and subcutaneous tissues. Angioedema episodes may be mediated by mast cells or bradykinin. The episodes could be idiopathic, in which the symptoms appear without any evident triggers, or stimulus-induced, in which they are induced by a specific stimulus or load.

The condition is accompanied by superficial urticaria in some cases. On the other hand, stimulus-induced angioedema is usually not accompanied by urticaria. Angioedema caused by bradykinin includes hereditary angioedema, angioedema due to acquired C1-INH wasting or loss of function in the context of blood disorders or autoantibodies, and drug-induced angioedema.

We report a case with recurrent angioedema that resulted in airway stenosis. Three unexplained episodes of laryngeal edema occurred over a period of two years and two tracheotomies were performed. During the third episode of laryngeal edema, nasal intubation was performed immediately after the onset. Initially, we suspected hereditary angioedema, but there were no apparent abnormalities in blood or genetic testing. The patient had stopped taking an angiotensin II receptor blocker three years ago, but has not had any more attacks over the eight-year period since the last episode. Cases of angioedema of undiagnosed cause should be followed up with caution. In cases of angioedema that progresses gradually on an hourly basis, the airway should be secured, even if there are only mildly abnormal findings.

Objective tinnitus is defined as tinnitus that can not only be heard by the individual, but also appreciated by a third party. A 10-year-old girl was referred to our hospital with a 3-month history of objective tinnitus in both ears. Her objective tinnitus could be heard synchronously with her blinking of the eyes. Jerky movements of the soft palate were also observed when the objective tinnitus occurred. Sonotubometry showed her Eustachian tube opening in synchronization with tinnitus. On the basis of these findings, the source of the objective tinnitus was considered to be a desorption sound of the lumen of the Eustachian tube. Conservative treatment with counseling resulted in improvement, and the patient stopped noticing her tinnitus.

In cases of objective tinnitus occurring synchronously with eye blinking, there are reports that the source of the sound is the ossicular muscle, but in some cases, such as in this case, the Eustachian tube is the sound source. It is thought that not only the tensor tympani muscle, but also the tensor veli palatini muscle is involved in the sound production. These two muscles share their innervation by the trigeminal nerve. Since the patient could also induce tinnitus without eye blinking, it was thought that the blinking might serve as a kind of “boost” to generate the objective tinnitus. Therefore, we believe that the trigeminal nerve, and not the facial nerve, may be involved in the production of the sounds. In cases of objective tinnitus occurring synchronously with eye blinking, it is necessary to observe the soft palate and perform sonotubometry.

Objective and method: From the viewpoint of new otolaryngologists, cases of otitis media with effusion (OME) caused by Eustachian tube dysfunction tend to be overlooked, while the mechanism of OME is gradually understood. Children in lower grades with tonsillitis, adenoid hyperplasia, sinusitis, and an immature Eustachian tube have been encountered. Children in upper grades with a habit of sniffing (HS), presenting for treatment by general practitioners, are also encountered. The training involved one case where insertion of a tympanic ventilation tube was requested by the general practitioner and another case with atelectasis. The conditions of the patients were assessed based on interviews, eardrum views, and assessment of the degree of ventilation of the Eustachian tube.

Result: The condition of children in lower grades improved with conservative treatment, and the condition of children in upper grades improved with cessation of HS.

Discussion: According to the 2015 medical treatment guidelines of OME, tympanic ventilation tubes should be inserted in cases of atelectasis, based on recommendation level A. However, the condition of the patients has been shown to improve with cessation of HS. Young otorhinolaryngologists often perform the insertion of tympanic ventilation tubes. It is important to consider not only the phenomena of hearing loss and exudate retention in the tympanum, but also the mechanism of exudate retention. We should make a careful judgement about whether to insert tympanic ventilation tubes or not, because the complications of tympanic ventilation tube insertion cannot be ignored.

We encountered two cases of refractory sniff-type patulous Eustachian tubes. Case 1, a 14-year-old girl visited our hospital with the chief complaint of “aural fullness”. The diagnosis of patulous Eustachian tube was made according to the diagnostic criteria for this condition. Conservative treatments, such as oral medicines, instillation of physiological saline, and application of adhesive tape on the tympanic membrane proved ineffective, and we performed ventilation tube insertion. Immediately after placement of the ventilation tube, the patient developed “auditory hyperacusis” (hypersensitivity to surrounding sounds), but this improved from the 16th day after insertion. Wearing earplugs was effective during this period when environmental noise was particularly noticeable. With the improvement of the auditory hyperacusis, the aural fullness also improved. It is important to explain to the patients about the possible development of auditory hyperacusis before the ventilation tube insertion. Case 2 was a 31-year-old woman with the chief complaint of “autophonia”. She also had anorexia nervosa. The diagnosis of patulous Eustachian tube was made according to the diagnostic criteria for this condition. We considered that the “sound invasion into the middle ear” had a greater effect on the pathology than the “pressure change in the middle ear” in this case, and inserted Kobayashi plugs into the Eustachian tube. We also inserted a ventilation tube in anticipation of continued sniffing and worsening of the tympanic membrane retraction due to negative pressure. Thereafter, the patient exhibited the behavior of sniffing while inserting a finger into the external auditory meatus, but we considered that there was no direct effect on the tympanic membrane. The Kobayashi plugs were replaced (sized up) during follow-up, and the ear symptoms, mainly autophonia, resolved.

Patients with insufficient closure of the Eustachian tubes visit otorhinolaryngology clinics at various stages of their life. Herein, we report two cases to enhance understanding about insufficient closure of Eustachian tubes.

The first case was a 37-year-old male patient who presented with right-sided ear fullness and autophony. The tympanic membrane was retracted and the tympanic cavity showed negative pressure. Sniff-type patulous Eustachian tube may be relieved by the doctor’s reassurance. To achieve this, it is necessary to improve the retraction of the tympanic membrane and release the negative pressure in the middle ear after providing the reassurance. It is also important for patients to understand pathophysiology and become accustomed to the new lifestyle without habitual sniffing. Since patulous Eustachian tubes could occur in individuals with various personalities, personalized medicine taking into account the patient individuality is required for treatment.

The second case was a 9-year-old elementary student who developed tympanic perforation after ventilation tube insertion. We performed tympanoplasty for the perforation. However, the patient started to exhibit habitual nasal sniffing after the operation, and 3 years later, his tympanic membrane was retracted. When should we perform tympanoplasty for this perforation? Improvement of the Eustachian tube function is an important condition for tympanoplasty. Otitis media with effusion in children is often cured by the age of 10 years. In that sense, the age for tympanoplasty is ideally after the age of 10.

On the other hand, there are cases that do not heal even after 10 years of age. Such cases often have insufficient closure of the Eustachian tubes that does not improve with age. In such cases, postoperative patulous Eustachian tube symptoms become prominent and the patients begin to exhibit sniffing. We call this “masked habitual sniffing.” It is necessary to persuade these to stop their habitual sniffing, but to understand the persuasion, we think the patient should at least be a junior high school student.