Thirty patients with advanced maxillary squamous sinus cancer were treated with superselective intra-arterial chemoradiotherapy from 2000 to 2013. To evaluate the treatment efficacy of the infused cisplatin dose, patients were divided into a low-dose group (<450mg/body of cisplatin, n=7, from 2000 to 2003) and a high-dose group (>600mg/body of cisplatin, n=23, from 2004 to 2013). No significant differences were observed in the initial treatment, progression-free survival, local control rate and the adverse effects associated with the two groups. The number of partial maxillectomies performed as salvage surgeries were significantly less in the high-dose group (P=0.005). In the high-dose group, the improvement in outcome was admitted compared with a previous report of our department. These results suggest that 450mg of cisplatin is insufficient to control advanced maxillary squamous sinus cancer, but 600mg of cisplatin is beneficial.

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Lund et al.¹⁾ defined an Onodi cell as a cell that develops laterally and/or superiorly to the sphenoid sinus. We²⁾ reported that the prevalence of OC was 27.4%, which was high, and that the prevalence of exposure of the optic canal in the posterior ethmoid region was 31%, which was also high. Therefore, a mass lesion in this area may cause optic neuropathy. I reported a case of optic neuropathy caused by paranasal fungal disease in an Onodi cell. An 84-year-female complained of right visual loss from late March. She was introduced from the ophthalmology department of our hospital to our department. The level of visual acuity was light perception only. Paranasal fungal disease was suspected due to the findings of paranasal CT scan and MRI. On April 9, right endoscopic sinus surgery was performed. A fungal ball filled the Onodi cell. There was a risk of carotid artery and optic nerve damage associated with its removal. However, only transient vision deterioration was achieved postoperatively by administering antifungal agent (voriconazole). The fungal diseases disappeared. Even visual acuity recovered to 20/20. This case is currently under observation. We applied both surgical treatment and antifungal agents. This contributed to control of the fungal disease and improvement of prognosis.

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Paranasal sinus diseases can disturb vision because the optic nerve is in close proximity to the paranasal sinuses. Such diseases require immediate medical treatment to avoid irreversible damage to the optic nerve. We retrospectively reviewed the records of 15 patients (male, n = 10; female, n = 5; mean age, 63.2 y; range, 9–81 y) admitted to our hospital with paranasal sinus disease accompanied by visual disturbance between April 2008 and March 2014. Patients with malignant tumor were excluded from this study. The patients were grouped according to whether they had paranasal sinus cyst (n = 7), sub-periosteal abscess of the orbit due to acute sinusitis or paranasal sinus cyst infection (n = 4), or fungal sinusitis (aspergillosis) (n = 4). The median interval between the onset of visual disturbance and surgery was 12 (range, 2–1825) days. All patients underwent endoscopic sinus surgery (ESS) and one also underwent craniotomy. Visual disturbance improved, remained unchanged, and became exacerbated in 10, two, and three patients, respectively. All patients with exacerbation had aspergillosis and MRI revealed thickening of the dura mater in two of them. The patients with aspergillosis were treated with steroid and antifungal agents in consideration of the fact that aspergillus can cause hypertrophic cranial pachymeningitis. Vision temporarily improved in these patients, but all of them ultimately became blind.

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The patient was a 42-year-old female in whom a granulation lesion was detected at the maxillary sinus by ESS and postoperative re-biopsy revealed positive results in Ziehl-Neelsen staining and liquid culture. Thus, this case was diagnosed as paranasal tuberculosis. Because there was a shadow in the lungs and sputum smear examination showed positive results in Ziehl-Neelsen staining, the patient was hospitalized in the tuberculosis ward and received systemic administration of anti-tuberculosis drugs, which led to negative results in sputum smear examination. However, because a paranasal shadow remained on the images, ESS was performed. The resected specimens were all negative in culture of tubercle bacilli and tubercle bacilli DNA-PCR/Ziehl-Neelsen stainings. The negative results of the tubercule bacilli culture of the specimens were confirmed and oral administration of anti-tuberculosis drugs was discontinued. At present, one year and five months later, no recurrence of the lesion has been found. For cases of paranasal tuberculosis in which the administration of anti-tuberculosis drugs, results in insufficient, the sinus surgery and evaluation of the treatment effect are considered to be an effective method. In addition, in refractory nasal/paranasal diseases or those which cannot be identified, while suspecting nasal/paranasal tuberculosis, it is important to perform repeated biopsies, cultures, and PCR.

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Eosinophilic chronic rhinosinusitis (ECRS) has increased nationwide. A new diagnostic criterion for ECRS has been proposed by the JESREC (Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis) Study. We diagnosed ECRS only in patients having typical clinical features before the JESREC criterion. This study examined the clinical features of ECRS considering the criterion by the JESREC Study and our department.Methods: The subjects were 321 patients with bilateral CRS who underwent initial endoscopic sinus surgery (ESS) in our department between January 2008 and December 2014. There were 206 men and 115 women with a mean age of 50 years old, ranging from 12 to 85 years old. Criterion by the JESREC was determined when a total score of the following four items was 11 or more: (i) bilateral lesions (3 points); (ii) nasal polyps (2 points); (iii) ethmoid sinus dominant or pansinusitis on CT (2 points); and (iv) blood eosinophils of 2%< ≤ 5% (4 points), 5%< ≤10% (8 points), and 10% < (10 points). Criterion by our department was determined when all the following conditions were completely fulfilled (i–iv): (i) symptoms of nasal congestion and olfactory disorder; (ii) bilateral chronic rhinosinusitis with nasal polyps; (iii) peripheral blood eosinophilia (>7.0%); and (iv) bilateral ethmoid sinus-dominant opacification in preoperative CT findings. In this study, we divided the subjects into four groups (A to D): Group A (fulfilling both criteria); Group B (fulfilling only JESREC criterion); Group C (fulfilling only our department criterion); and Group D (fulfilling neither criterion). We retrospectively analyzed the preoperative JESREC scores, peripheral blood eosinophils (%), olfaction (mean T&T recognition thresholds and intravenous olfaction test), radiological findings (Lund-Mackay CT scoring system and E/M ratio), and the presence of aspirin-induced asthma (AIA).Results: Groups A, B, and D consisted of 64, 130, and 127 patients respectively. No patients were in Group C. The mean JESREC score, percentage of peripheral blood eosinophils, T&T recognition threshold, CT score, E/M ratio, and number of patients with AIA in Group A were significantly higher than those in Group D. The preoperative conditions of ECRS in Groups A and B were significantly severer than those in Group D (non-ECRS).Conclusion: All patients diagnosed by our department criterion were in severe conditions, and included the patients by the JESREC criterion.

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Superselective intra-arterial infusion therapy of high-dose cisplatin and concomitant radiotherapy (RADPLAT) has been employed to treat advanced maxillary cancer with promising outcomes. This report describes the protocols and results of RADPLAT that we have performed over the past 6 years since August 2009 on 17 patients with maxillary squamous cell carcinoma. Our standard procedure involved weekly administration of 100mg/m² of cisplatin via superselective arterial injection over the course of four weeks (i.e., a total of four times) with concomitant radiotherapy. For those with insufficient tumor reduction after 40Gy of radiation, this weekly chemotherapy was continued until radiotherapy ended. Potential acute side effects we noted include cerebral infarction (one patient, treated early on in our studies) and neutropenia (one patient). No patient exhibited renal dysfunction. This implies RADPLAT is feasible in institutions with experience conducting the procedure. The late effects we observed include maxillary osteomyelitis that lasted more than 1 year (three patients) and nasolacrimal obstruction (five patients). Dacryocystorhinostomies were performed on three patients with nasolacrimal obstruction, and their lacrimation improved. The overall outcomes of our RADPLAT procedures were similar to those of previous reports, with a high response rate (88.2%) and a high local control rate (82.4%). More specifically, the local control rate of T3 and T4a cases was 92.3% (12/13), while that of T4b was only 25% (1/4). We conclude that RADPLAT is highly effective for T3 and T4a maxillary squamous cell carcinoma, but further optimization is required to improve results in T4b cases.

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Endoscopic modified Lothrop procedure (EMLP), or Draf type III sinusotomy, is an endoscopic extended frontal sinus surgery to treat recalcitrant rhinosinusitis, frontal sinus mucoceles, and frontal sinus tumors. The outside-in approach is a new surgical concept of extended frontal sinus surgery and is a modified EMLP to open the bilateral frontal sinus outside from the frontal recess and to create a Lothrop cavity. The outside-in frontal drill-out technique emphasizes the early identification of the first olfactory neuron, maximization of bone removal, and preservation of the posterior table mucosa. In the present study, we describe the frontal drill-out technique and our results of outside-in approaches for recalcitrant frontal sinus diseases. Ten patients, including 2 with frontal sinusitis, 3 with mucoceles with contra lateral sinusitis, 3 with multilocular cyst, and 2 with inverted papilloma, underwent outside-in approaches at our hospital. All cases were successfully treated by the outside-in approach of EMLP. No complications were observed postoperatively. The advantages of the outside-in approach include the following: it provides an unobstructed view, anatomic limits can be identified early, bone removal is fast and efficient, it is safe, and it is a robust technique based upon fixed anatomical landmarks.

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The pathological histology of nasal tumors is diverse. Some tumors are diagnosed at an early stage because they cause nasal bleeding or occlusion. We examined nasal tumors that were diagnosed at our hospital. The number of patients diagnosed with nasal tumor between April 2008 and March 2014 was 48 at our hospital. We excluded cases of granuloma and Wegener granulomatosis, and examined 35 cases. The most common complaint was nasal occlusion (20 cases), followed by nasal bleeding (7 cases). Five cases were diagnosed accidentally. In terms of pathological histology, there were benign tumors in 27 cases (19 cases of papilloma, 7 cases of hemangioma, and 1 case of pleomorphic adenoma) and malignant tumors in 8 cases (3 cases of malignant lymphoma, 3 cases of squamous cell carcinoma, 1 case of small cell carcinoma, and 1 case of adenocarcinoma). The case of adenocarcinoma was diagnosed as metastasis of colon carcinoma, because of sigmoid colon and liver metastasis. Treated for frequent nasal bleeding, the patient received palliative radiation, resulting in tumor reduction and control of bleeding. Metastasis to the nasal cavity from colon carcinoma is rare.

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I have performed nasal dermoplasty for refractory epistaxis in patients with hereditary hemorrhagic telangiectasia for 25 years. The associated surgical procedures have changed over time. Here, I present the history of such treatment. Saunders first proposed septal dermoplasty in 1960 with the purpose of decreasing the frequency and severity of epistaxis by removing the affected mucosa and then performing a skin graft. At first, surgery was confined to one side of the nose at a time, and the other side was treated several months later. However, from the 8th case onwards both sides were treated simultaneously. Bleeding often occurred in the uppermost part of the septum because the mucosa there was left intact to provide a suture site. From 2008, I circumferentially extended the grafting area to the anterior half of the nasal cavity. Intraoperative bleeding can be controlled by the topical application of Kaltostat^TM (calcium/sodium alginate) as a wound dressing. In patients with large septal perforations, the graft is likely to fail, which often results in postoperative bleeding. I developed the MW method for such cases. Maniceps^TM, a suturing device for deep surgical operations, is a useful tool for transfixion suturing. Using this device, I can easily insert transfixion sutures at deep locations. Recent modifications have included changes in the surface removal procedure (from submucosal detachment to curettage), discontinuance of an alar rim incision, and the introduction of endoscopy. Although the complete cessation of epistaxis is difficult to achieve, combination treatment involving Coblator^TM ablation or the topical application of timolol seems to result in better control.

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