Surgical management of refractory or recurrent frontal sinus disease poses a unique challenge for 
endoscopic sinus surgeons due to complex and variable anatomy, difficulty in transnasal visualization, and a propensity for inadvertent scarring and restenosis. The endoscopic modified Lothrop procedure (EMLP) is an endoscopic procedure of frontal sinus surgery removing the frontal sinus floor, intersinus septum, and superior nasal septum. This procedure creates the largest possible opening from the floor of the frontal sinus into the nasal cavity for efficient drainage. We retrospectively analyzed 5 cases of frontal sinus lesion treated with EMLP in Kurashiki Central Hospital between 2011 and 2012. Except for one incidence of CSF leak, which was managed at the time of 
surgery, no complications were observed during EMLP, such as tension pneumocephalus and posterior table dehiscence. All five patients reported symptomatic improvement and no reocclusion was seen after the surgery. The most notable postoperative problem is narrowing of the opening created due to regeneration of the bone tissue. This is likely prevented by maximally preserving mucosal membrane during the operation as well as by covering exposed bone surfaces with mucosal flap. Thus, although a larger sample size and more extensive follow-up would be necessary to make a general and definitive conclusion, we suggest that EMLP is efficacious in treating refractory or recurrent frontal sinus disease in a short period based on subjective symptom improvement and the need for further surgery.

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The orbital periosteum contains two distinct layers. We present a case of a 35-year-old man with an 
abscess between two distinct layers of the orbital periosteum. The patient complained of left forehead headache. The headache was refractory to antibiotics, and swelling of the left eyelid occurred. CT scan showed a left 
orbital subperiosteal abscess. We performed two endoscopic sinus surgeries. We did not remove the lamina papyracea in the first surgery. Postoperative swelling of the left eyelid worsened. In the second surgery, we 
exfoliated the orbital periosteum, but the abscess was not drained from the orbital subperiosteal space. We 
exfoliated between the two distinct layers of the periosteum, and the abscess was drained. After the second 
surgery, the patient was doing well.

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Background: The amount of cedar pollen influences the severity of symptoms of pollinosis. Therefore, it is necessary to clarify the correlation between pollen count, symptoms, and the effectiveness of several treatments. Methods: Subjects consisted of patients who consulted our hospital and ENT clinic during the peak cedar pollen-exposure season between 2010 and 2013. Patients were divided into two groups as follows: those who had taken only pranlukast twice daily prior to enrolling in the study (treated group) and those patients without any previous treatment (non-treated group). Patients consulted our hospital or ENT clinic during the peak 
exposure cedar pollen season, and they were asked about their symptoms and QOL using the Japanese Rhinoconjunctivitis Quality of Life Questionnaire (JRQLQ). Results: Patients in the non-treated group had worse total symptom scores. No significant symptomatic changes were observed among patients in the treated group, despite annual differences in pollen count between 2010 and 2013. These results suggest that administration of pranlukast before the cedar pollen season may 
suppress symptoms regardless of the amount of pollen. Conclusion: Pranlukast is effective for prophylactic treatment of pollinosis.

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We retrospectively analyzed the postoperative olfactory changes in 109 adult patients with olfactory disorder due to chronic rhinosinusitis who underwent endoscopic sinus surgery (ESS) between 2007 and 2013. There were 60 men and 49 women. Median age was 50 years (20–79). Median follow-up period after ESS was 12 months (3–79). Olfaction was evaluated using T&T olfactometry and intravenous olfaction test. In the longitudinal data analysis, the proportion with improvement was 66% (40/66) within 6 months, but this decreased as time passed after surgery. The postoperative course of olfactory acuity could be classified into four courses: sustained improvement (50%, n=29); gradual improvement (7%, n=4); deterioration (14%, n=8); and no change (29%, n=17). On average, the mean T&T recognition threshold significantly improved from 4.9±1.4 before ESS to 
3.9±1.7 after it (n=109, p<0.0001), and the proportion with improvement was 52% (57/109) in total. The mean T&T recognition threshold (2.6±1.3, n=57) in the improvement group was significantly better than in the 
unchanged group (5.2±0.9, n=52, p<0.0001). The positive rates of preoperative intravenous olfaction test showed a significant difference between the improvement group (95%) and the unchanged group (79%, p=0.020).

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Among all tumors of sinonasal origin, neoplasms of the nasal septum are rare, regardless of their benignity or malignancy. Squamous cell carcinoma of the nasal septum is extremely rare. Certain occupations and smoking are thought to be related to its carcinogenesis, and it is known to show a tendency for field cancerization. Therefore, these diseases often develop in patients who have already been treated for another head and neck cancer. As such, when we treat them, a limit to treatment may occur because of such previous therapy. In this manuscript, we report 2 patients with squamous cell carcinoma of the nasal septum who had already received previous therapy. We chose individualized treatment in accordance with each of their pathologies. Both of them could be detected by nasal endoscopy. Thus, when we treat patients with head and neck cancer, we should not forget careful inspection of the nasal cavity.

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Optic nerve decompression is required to recover vision that has been impaired by compression of the optic nerve as a result of injuries to the face or head, or neoplasm in the orbit. There are fundamentally three routes to access the optic canal: through the skull, the orbit, or the nasal cavity. As an otolaryngologist who regularly performs endoscopic sinus surgeries, access through the nasal cavity using an endoscope is a preferred route. Moreover, endoscopic endonasal optic nerve decompression has advantages over the other two routes, as it is minimally invasive with no skin incision on the face and, in addition, allows visualization of the optic canal and the optic nerve in greater detail. A search of the literature published in Japan found only a few reports of endoscopic endonasal optic nerve decompression, all of which were performed to alleviate visual dysfunction caused by fracture of the optic canal. Here we report a case in which vision impairment due to a neoplastic lesion was treated by endoscopic endonasal optic nerve decompression. A 44-year-old man suffered deteriorated vision due to optic canal destruction by a paranasal sinus cyst. Emergency endoscopic optic nerve decompression was performed through the nasal cavity, and the patient exhibited full recovery of visual functions. We suggest that endoscopic endonasal optic nerve decompression is minimally invasive and efficacious in treating optic nerve disorder not only by trauma, but also by neoplasm in the orbit.

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Osteoma is the most common bone tumor of the facial region. It is a benign, slowly growing neoplasm 
that generally arises from the frontal sinus. Symptomatic patients with chronic rhinosinusitis due to tumor 
obstruction, massive headaches or facial deformity should undergo operation. We report a case of osteoma of the frontal recess. The patient complained of a headache. This was probably due to obstruction of the natural drainage of the frontal sinus, which leads to chronic frontal sinusitis. The patient was treated successfully by the endoscopic modified Lothrop procedure that involved complete removal of the osteoma and wide opening 
of the frontal sinus.

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For blowout fractures of the orbital floor, surgical procedures have routinely involved a transantral, transorbital, or endonasal endoscopic approach, or some combination of them. We have adopted a combination of transantral and transorbital approaches, a combined approach, since 2009. In the transantral approach, the 
orbital tissue can be lifted upward through the maxillary sinus using endoscopes. Using a transorbital approach, the orbital floor can be approached to pull the orbital tissue upward via subciliary incision. The transorbital 
approach is useful for fractures in the anterior part of the orbital floor, but has less benefit for fractures in the posterior part. A combined approach overcomes this shortcoming without any postoperative esthetic complications. This report describes two patients with blowout fractures in the orbital floor who underwent reconstruction using a combined approach.

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A considerable number of patients with paranasal sinus carcinoma or nasopharyngeal carcinoma are treated with radiation therapy. However, endoscopic sinus surgery (ESS) is on rare occasions indicated for refractory sinusitis in patients after radiation therapy, however, the indication and complications of ESS are not well known. We report a case of ESS performed after radiation therapy for frontal sinus carcinoma. An 82-year-old woman was referred to our department for frontal sinus carcinoma. The locally advanced tumor successfully regressed with 60 Gy of radiation therapy. Eight months later, she developed acute sinusitis that was refractory to antibiotic treatment. ESS was performed to establish a drainage route and prevent the spread of infection through the bony defect of the anterior skull base into the intracranial space. ESS was performed safely with 
no intraoperative complications, although tumor recurrence was found in the frontal sinus. After surgery, 
edematous change was noted in the paranasal sinus mucosa and then subsided. It has been reported that ESS after radiation increases the risks of intraoperative complications and affects wound healing after ESS. Radiation hampers mucosal function, including mucociliary clearance in the paranasal sinuses, which may 
prolong sinusitis after ESS. Refractory sinusitis after radiation therapy can be considered as an indication 
for ESS, however, the effectiveness and complications of ESS need to be studied in a larger group of patients. We have reviewed the pathophysiology of the irradiated mucosa, and the surgical complications after ESS in patients with postirradiated paranasal sinuses.

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Angioleiomyoma is a benign tumor that is seen in the head and neck region. We report a case of angioleiomyoma occurring in the nasal septum. A 65-year-old woman had received nasal continuous positive airway pressure (nCPAP) treatment for obstructive sleep apnea syndrome for 3 months. She visited our hospital 
because of recurent epistaxis, and a physical examination revealed a soft mass in the left side of nasal septum. CT scan and MRI with enhancement showed a well-enhanced mass in the left side of nasal septum without bone destruction. Biopsy revealed angioleiomyoma. The tumor was excised by a transnasal approach. Histological and immunohistochemical findings yielded a definitive diagnosis of angioleiomyoma. Angioleiomyoma should be considered in the differential diagnosis of any well-circumscribed, hypervascular, soft-tissue mass arising in the submucosal tissue of the nasal septum. We believe that the angioleiomyoma was caused by the nCPAP treatment in this case. Therefore, it is important to check the upper airway including the nasal cavity during nCPAP treatment.

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Actinomycosis is an indolent, slowly progressive infection caused by anaerobic bacteria, primarily from the genus Actinomyces, which normally colonize the mouth, bronchial tubes, colon, and vagina. Disruption of 
mucosa may lead to infection of virtually any site. Four clinical forms of actinomycosis are recognized: 1) 
cervicofacial, 2) thoracic, 3) abdominal, and 4) genital. About 40–60% of cases occur in the head and neck 
region, but reports of involvement of the nose and sinuses are extremely rare. We report here a case of actinomycosis of the nasal cavity. A 19-year-old female visited our clinic with a complaint of headache and left nasal obstruction. She did not have maxillofacial or oral trauma or dental treatment such as tooth extraction. Granulation and a blackish brown lesion were found in the inferior meatus. Plain CT revealed mucosal hypertrophy of the left inferior turbinate and calcification in the inferior meatus. A biopsy was performed, and the lesion was diagnosed as actinomycosis by histopathological examination. The patient was treated with oral penicillin (AMPC 1500 mg/day) for 8 weeks and the residual lesion in the inferior meatus was excised under topical anesthesia. Then, oral penicillin (AMPC 1500 mg/day) was administered again for 4 weeks. However, since the paranasal lesion remained, endoscopic sinus surgery (ESS) was performed under general anesthesia 4 months after the first surgery. To date, one year after the ESS, no recurrence has been observed.

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This report describes the treatment of a frontal sinus cyst in a patient who suffered long-term exposure to nitric acid. The 66-year-old male patient had no history of nasal surgery. He was employed at a stainless steel processing facility for 50 years in a position requiring the use of high-temperature, highly concentrated nitric acid during scale cleaning of welded metal. During this time (mid-1960s to mid-1970s), protective masks were not generally worn, and the patient was thus exposed to vaporized nitric acid and its by-product, nitrogen oxide, for a 
prolonged period. In mid-January 2013, he was examined by a local physician for a chief complaint of swelling around the left eye. A frontal sinus cyst was identified on a cranial MRI, and the patient was referred to our facility for 
examination. The imaging suggested a possible retention cyst, and while no visual or ocular motility impairment was found on initial examination, surgery was recommend at the earliest opportunity to treat the partial bone erosion. That same month, a left frontal sinus endoscopic frontal sinusotomy (Draf IIb) was performed. The surgery opened up the left frontal sinus cyst but did not alleviate the left upper eyelid swelling. In addition, we performed a skin incision for eyelid skin, which only resulted in the spread of a small volume of pus. There were no subsequent complications, and the patient was discharged 3 days postoperatively. The swelling at 
the upper left eyelid resolved approximately 1 week after discharge from the hospital and was attributed to spreading inflammation from the cyst. The patient recovered well and is currently receiving outpatient 
follow-up examinations. There are no known reports to date describing a causative relationship between nitric acid exposure and the development of frontal sinus cysts or nasal septum perforation. However, nitric acid and nitrogen oxide are known to damage the mucous membranes. This patient had no history of nasal surgery, which suggests that the long-term exposure to nitric acid may have caused the frontal sinus cyst and nasal septum perforation.

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[in Japanese]

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