We report clinically evaluating and surgically treating two cases of acquired choanal stenosis or atresia. Case 1: A 69-year-old woman reporting long-term nasal obstruction was found in workups including fiberscopy and computed tomography (CT) to have choanal stenosis, necessitating transnasal surgery. We resected the stenotic lesion and posterior nasal septum to avoid restenosis. One year postoperatively, the choana was slightly stenotic but she reported no nasal symptoms. Case 2: A 72-year-old woman reporting bilateral ear fullness and nasal obstruction was diagnosed with choanal atresia based on fiberscopy, CT, and magnetic resonance imaging (MRI). As in case 1, she underwent transnasal surgery. Postoperatively, however, the choana became increasingly stenotic and atresial in only one month and did not respond to surgery. We finally succeeded in making the choana patent with a tracheal stent made to fit the stenotic choana. The woman's only complaint thereafter was slight unnatural feeling.

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For a period of about 25 years, laser surgery of the inferior turbinate has been considered a simple and effective surgical treatment with a low complication rate and has been used widely by many ENT surgeons throughout Japan. In the present study, we assessed the clinical efficacy of carbon dioxide laser treatment for a period of up to 5 years. Treatments were performed on an outpatient basis in up to three consecutive sessions under local anesthesia. Outcome was evaluated by daily nasal symptom reports and patient interviews according to the Practical Guidelines for the Management of Allergic Rhinitis in Japan, 2009. Six months after treatment, all the nasal symptoms and total severity had remarkably improved in all the patients. At a 5-year follow-up examination, the effectiveness of the treatment for nasal sneezing, discharge, obstruction, and total severity had persisted in 48.5%, 54.3%, 62.7%, and 40% of the patients, respectively. The decrease in the mean symptom score for nasal obstruction remained unchanged during the follow-up period. Altogether, 71.4% of the patients after 6 months and 65.7% of the patients after 5 years showed a stable non-medicated condition without adversely compromising their nasal symptoms during their daily life. The results of the present study substantiate our previous conclusion that laser surgery is an effective treatment for allergic patients refractory to medication.

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Background: As guidelines indicate initial (prophylactic) therapy is useful in Japanese cedar pollinosis. When to initiate therapy depends on when cedar scattering starts, which differs annually and is unpredictable.
Methods: We statistically studied how temperature related to start date in 1994 and 2010.
Results: The start date in Tsu correlated positively and statistically significantly with average, maximum, and minimum mid-November temperature, indicating that the start date was earlier if mid-November temperature was cooler. Based on these results, we checked the relationship in 30 cities in Japan, finding that the start date was related to average mid-November temperature from northern Kyushu in Western Japan to Kanto in eastern Japan, excluding the Sea of Japan coast and northern Japan.
Conclusion: Initial Japanese cedar pollinosis therapy can be started from the predictable pollen scattering start date.

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The very narrow nasal cavity complicates endoscope endonasal sinus surgery due to hard or thick osseous tissue aggravated by the simultaneous insertion of the drill, endoscope, and other instruments. We found a high-speed eMAX2plus^® drill (ANSPACH, Palm Beach Garden, FL, US) particularly useful in 2 cases one of choanal atresia in a 4-year-old and one of postoperative sphenoidal cyst in a 69-year-old. The drill very effectively facilitated opening of the firm osseous tissue in both cases.

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Fungal sinusitis incidence is increasing with societal aging and steroids administration, and head imaging has lead to increased detection. With nebulizers and medicinal therapy mostly ineffective in treating fungal sinusitis, surgery becomes the preferred choice.
Subjects with maxillary fungal sinusitis undergoing endoscopic sinus surgery between 2000 and 2009 numbered 38: 19 men and 19 women, aged 30-80 years (average: 66.4 years).
Of these, 15 underwent mid-meatus antrostomy and 23 through mid and inferior meatus. One underwent reoperation through the inferior meatus. Fungal sinusitis recurred in 4 cases, 2 requiring a second surgery. One underwent mid-meatus antrostomy again due to mid-meatal window closure. The other underwent inferior meatus antrostomy due to a fungal ball at the bottom of the maxillary sinus. The antrostomy approach was decided after confirming fungal ball location in the maxillary sinus using computed tomography (CT) and magnetic resonance imaging (MRI). If the fungal ball is near the mid-meatal window, antrostomy should be through the mid-meatus, while location at the bottom of the maxillary sinus or anterior wall requires antrostomy through the mid-meatus and inferior meatus.
With surgery through the inferior meatus was useful in 2 subjects, maintenance of the nasoantral window is vital in preventing fungal sinusitis recurrence. We tried to use the inferior meatal mucosal flap during antrostomy. The nasoantral window opening ratio was 88.9% for this procedure.

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The major reason for developing endoscopic transsphenoidal pituitary tumor resection is to minimize intranasal complications and to provide good operative visualization. The fully endoscopic two-surgeon pituitary surgery conducted for one year involved a neurosurgeon and an otolaryngologist. Transnasal binostril approach enabled multiple instruments to be used simultaneously during tumor resection, which is very helpful when the descending diaphragm or bleeding compromises the surgical view. Using computed tomography, we preoperatively checked the sphenoethmoidal (Onodi) cell location. We then removed the lower two-thirds of the superior turbinate and conducted posterior ethmoidectomy for subjects whose optic canal was in the Onodi cell. The superior turbinate was preserved in 58.5% of patients.
Our otolaryngologist-neurosurgeon approach for pituitary tumors has the advantages of a wide operative view and of nasal structure preservation.

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Epithelial-derived thymic stromal lymphopoietin (TSLP) triggers dendritic cell (DC)-mediated Th2-type inflammatory responses and is a master switch for allergic inflammatory diseases. In the present study, to elucidate the role of TSLP in human nasal mucosa including allergic rhinitis, the expression and induction of TSLP and the effects of TSLP on the tight junctional barrier of human nasal epithelial cells (HNECs) have been investigated. We found high expression of TSLP in the epithelium from patients with allergic rhinitis with recruitment and infiltration of DCs. In vitro, TSLP was significantly produced from HNECs after treatment with a toll-like receptor 2 (TLR2) ligand, P₃CSK₄, TLR3 ligand, poly (I: C), and a mixture of IL-1β and TNF-α. Treatment with TSLP rapidly enhanced the barrier function of cultured HNECs, together with an increase of tightjunction proteins claudin-1, -4, -7, and occludin. Furthermore, TSLP could induce claudin-7 expression in mouse DC line XS52. By immunocytochemistry, claudin-7-immunoreactivity was observed at cell borders and in the cytoplasm of XS52 cells after treatment with TSLP, whereas in the control it was observed in the cytoplasm. These findings indicate that nasal epithelial-derived TSLP plays a key role in allergic rhinitis and may control tight junctions of epithelial cells and DCs to preserve the epithelial barrier and promote direct sampling of antigens by DCs during the early stage of allergic rhinitis.

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It is essential to assess adequately the severity and select the appropriate antimicrobial agents in the treatment of acute rhinosinusitis. In 2009, the clinical guideline for acute rhinosinusitis is proposed by the Japanese Society of Rhinology. In the guidline, the clinical scoring system for the diagnosis and treatment of acute rhinosinusitis, based on three clinical symptoms and three nasal findings to evaluate quantitatively the severity and the clinical course is shown. The guidleine concluds that muco-purulent nasal discharge and/or post nasal discharge (score: 0, 2, 4), facial pain for adults and irritability/moist cogh for children (score: 0, 1, 2) and rhinorrhea (score: 0, 1, 2) should be selected as evaluation items in the clinical scoring system, and classifies the severity as mild (total score: 1-3), moderate (total score: 4-6) and severe (total score: 7-8), by evaluating the consistency with assessment of doctors. The clinical severity of acute rhinosinusitis depending on the clinical scoreing system well represents those defined by otorhinolaryngology specalist.

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