The Japanese Rhinologic Society has held “Hands-on Seminar on Basic Research for Clinicians” led by the Society since 2014. These seminars are planned with the aim of raising the motivation and research skills of clinical otorhinolaryngologists toward basic research, and in turn to encourage inter-disciplinary collaboration through research with universities. The fifth seminar was held at the 57th Annual Meeting of the Japanese Rhinologic Society (Asahikawa) including four different topics, isolation of single cells from nasal samples, ELISA, Western blot, and CRISPER-Cas9. Based on the questionnaire, the participants had a high need and satisfaction of these research seminars. Because this seminar is a great opportunity for rhinologists to obtain an idea to expand the avenue of basic understanding of rhinologic disorders, this seminar should be continued as far as there is a demand.
Introduction: Using an olfactory term table makes it easier to determine and name an odor when using T&T olfactometer. This method may have the advantage that it improves the recognition threshold of the odor. This study reports the results of a comparison between using and not using an olfactory term table and T&T olfactometer.
Materials and methods: Sixty patients who visited the Ikeda Municipal Hospital between April 2016 and May 2017 received checkups with T&T olfactometer and also answered a self-administered odor questionnaire (SAOQ). The patients were categorized into an olfactory term table usage group and a non-usage group, according to the time of examination. The results of recognition threshold, detection threshold, and the difference between detection and recognition thresholds with T&T olfactometer, as well an alinamin test and self-administered odor questionnaire were retrospectively compared.
Results: The olfactory term table usage and non-usage groups consisted of 37 and 23 patients, recpectively. The recognition threshold was significantly lower in the usage group than that in non-usage group (p = 0.003). The difference between detection and recognition thresholds was significantly lower in the usage group than that in non-usage group (p = 0.048). The detection threshold and SAOQ score were not significantly different between the groups. Therefore, we assumed that although olfactory function was similar, the recognition threshold was improved after using an olfactory term table over that when not using an olfactory term table.
Conclusion: We found that an olfactory term table influenced the recognition threshold in T&T olfactometer. It is necessary to determine whether to use an olfactory term table when using T&T olfactometer.
The isolated sphenoid sinus disease is sometimes found by diagnostic imaging. Patients suffer from several kinds of symptom, not only postnasal drips and chronic cough but impaired eyesight and eyeball movement block. Therefore when the diagnosis is difficult only with diagnostic imaging, it is necessary to do biopsy or experimental opening by endoscopic sinus surgery. We experienced an ectopic pituitary adenoma case, which we could not rule out malignant disease only with imaging.
We also experienced an inflammation case which we considered the destruction type mycosis and we performed an urgent operation.
For future examination, we report the isolated sphenoid sinus disease with our operation cases.
Intracranial penetrating injury other than gunshot wounds and knife stabbings is rare. Herein, we describe a 57-year-old man in whom a ballpoint pen that he had taken in transorally penetrated the sella turcica and cranium.
The patient had been admitted to another hospital because of schizophrenia. He attempted suicide and was seen piercing a toothbrush and ballpoint pen into his oral cavity. Although the medical condition of the patient did not change, a computed tomographic (CT) scan of the head revealed sella turcica fracture and pneumocephalus, as well as a spiral metallic foreign body in the left sphenoidal sinus. He was then transferred to the neurosurgery department of our hospital. Antibiotic treatment was started on the same day and we received a consultation request on the second day of hospitalization. At the time of examination, a mucosal laceration was observed from the hard palate to the soft palate, and a spring was found in the left nasal cavity. The patient’s state of consciousness was the same as that before the injury; no symptoms such as neurological deficits, eye movement disorder, rhinorrhea, or headache were observed. The spring in the nasal cavity was removed but no leakage of spinal fluid was observed. The CT scan of the head taken at our hospital showed a cylindrical, high-density area in the left sphenoidal sinus, and it was believed that a plastic mouthpiece had remained there. As this could cause infection, it was removed surgically under general anesthesia. After surgery, the patient had no major complications, and was transferred to the original hospital.
The orbital and nasal cavities are relatively thin bone areas in the skull, and such areas are easier to penetrate. Even if the immediate symptoms after injury are minor, complications such as meningitis and brain abscess may develop eventually and the prognosis may be poor. Thus, in addition to complete surgical removal of the cause of injury, adequate imaging examination and careful follow-up are indispensable.
In spontaneous cerebrospinal fluid (CSF) rhinorrhea, nasal discharge containing CSF is partially caused by skull base defects unrelated to trauma, surgery, malformation, or tumor. Typically, this condition occurs in middle-aged overweight women and is associated with a high frequency of idiopathic intracranial hypertension. The most common symptom is persistent unilateral watery nasal discharge. Since, patients with spontaneous CSF rhinorrhea are at risk for developing purulent meningitis, it important for otolaryngologists to be familiar with this condition.
Management of idiopathic CSF leaks often requires surgery, because skull base defects rarely resolve without intervention. Recently, endoscopic endonasal surgery with multilayer closure has become the gold standard for stopping spontaneous CSF leaks. For successful surgery, it is important to detect the sites of the fistula accurately before surgery. High-resolution CT (HRCT) should be performed initially for localizing skull base defects, and MR cisternography (MRC) is also a common diagnostic modality. CSF leaks can be visualized as a hypersignal intensity on coronal MRC images.
Herein, we report the successful management of a case of spontaneous CSF rhinorrhea in the olfactory cleft that was treated with endonasal endoscopic management. We recommend using MRC for localizing small skull base fistulas followed endoscopic repair with the multilayer closure technique including local pedicle flaps for treatment.
IgG4-related disease is a systemic disease characterized by abundant infiltration of IgG4-positive plasmacytes in various organs, but It rarely includes ophthalmic and sinus diseases. Here, we report two cases of IgG4-related ophthalmic disease, including the difficulties involved in their diagnosis and the usefulness of surgery in the Department of Otolaryngology.
Case 1 was a 60-year-old man with chief complaints of worsening of right vision and a protruding right eye. Sinus computed tomography (CT) and magnetic resonance imaging (MRI) revealed bilateral moderate pan-nasal sinusitis and swelling of the bilateral rectus inferior muscle. Oral administration of 20mg of prednisolone (PSL) was started immediately because of progressive reduction in visual acuity caused by right optic neuritis. Endoscopic sinus surgery (ESS) was performed 1 week later, but the sinus mucosa had already normalized. As the PSL dose was reduced, visual acuity worsened and eyeball protrusion recurred. Therefore, PSL was re-administered. Sinus mucosal biopsies were performed several times, but inflammatory findings were not definitive and a pathological diagnosis could not be confirmed. The serum IgG4 level was elevated to 264mg/dl. Based on the clinical course, we decided that the case was IgG4-related ophthalmic disease with optic neuritis and started long-term PSL administration. Good control of symptoms was achieved with this treatment.
Case 2 was a 44-year-old man with chief complaints of left eye protrusion and diplopia. Paranasal sinus CT and MRI revealed hypertrophy of the extraocular muscles, masses in the second branch of the bilateral trigeminal nerve predominantly on the left side, and mild enlargement of the bilateral lacrimal glands. The serum IgG4 level was highly elevated to 864mg/dl. For a definitive diagnosis, maxillary sinus fundus surgery was performed to remove the mass. The pathological diagnosis was IgG4-related disease. The course was good due to oral treatment with steroids.
Knowledge of concepts, classifications, causes, diagnosis, and treatment for olfactory disturbances has expanded since publication of the Olfactory Disturbance Clinical Practice guidelines. Here, we report three cases of patients with conductive olfactory dysfunction caused by olfactory cleft abnormalities. Each case was initially considered to be unexplained olfactory dysfunction on the basis of nasal findings, but was correctly diagnosed by nasal computed tomography (CT). Case 1 was a 24-year-old woman with a history of allergic rhinitis who presented with a complaint of olfactory dysfunction. Nasal CT showed inversion of the superior turbinate, and her olfaction improved after the olfactory cleft was widened by nasal treatment. Case 2 was a 50-year-old woman with a history of surgery for eosinophilic sinusitis who presented with unstable and variable olfaction. Inversion of the superior turbinate was observed on nasal CT, and her olfaction changed depending on the condition of the olfactory cleft. Case 3 was a 17-year-old man with a history of chronic sinusitis who sporadically visited a general practitioner with complaints of persistent olfactory disturbance. We investigated the cause of olfactory disturbance and detected inversion of the superior turbinate on nasal CT. His olfaction showed evident improvement after middle turbinate fenestration for widening of the olfactory cleft. Thus, all three patients exhibited olfactory cleft narrowing caused by inversion of the superior turbinate on nasal CT, and this was considered to be the cause of their conductive olfactory dysfunction because clear improvement was seen after the olfactory cleft was widened by nasal treatment and middle turbinate fenestration. The findings from these cases suggest the importance of checking for olfactory cleft abnormalities on nasal CT when patients have severe olfactory disturbance with unknown causes. Moreover, endoscopic endonasal sinus surgery, including middle turbinate fenestration, can effectively improve olfaction through permanent structural improvements.
Unlike in bilateral unilateral sinus disease, in unilateral sinus disease, it is necessary to consider fungal disease and tumor as differential diagnoses, because the definitive diagnosis of these conditions often require surgery, and thus, more accurate preoperative diagnosis is important. For the purpose of clarifying the proportion of these diseases and the useful examinations and findings for diagnosis, we reviewed the statistics of the diseases and the usefulness of the preoperative examination in the surgical cases of unilateral sinus disease. In the present study, cases of unilateral sinus disease for which surgery was performed at our hospital between January 2013 and December 2017 were included. Cases of postoperative cysts were excluded. The parameters retrospectively assessed were age, sex, symptom, CT findings, MRI findings, preoperative biopsy results, preoperative diagnosis / postoperative diagnosis and their concordance rates. In total, 145 cases were included, of which 54 were the most frequently observed chronic non-invasive fungal sinusitis, 42 were chronic sinusitis, 24 were paranasal papilloma, 12 were odontogenic sinusitis, 3 were squamous cell carcinoma, 2 were primary paranasal cyst, 2 were acute invasive fungal sinusitis, and 1 was “other diseases.” Assessment of the usefulness of the aforementioned parameters in the diagnosis of each disease revealed that MRI was considered to be useful for preoperative diagnosis of many unilateral sinus diseases such as chronic sinusitis, paranasal papilloma, fungal sinusitis, and malignant tumor, excluding odontogenic sinusitis. In conclusion, MRI is useful for the diagnosis of unilateral sinus disease, and we think that it should be positively enforced in cases where establishing a diagnosis via CT is difficult.
A 67-year-old diabetic male who presented with a two-month history of double vision and impaired visual acuity was referred to Nara Prefectural General Medical Center. Computed tomography showed a lesion within the left maxillary, ethmoid, and sphenoid sinuses and pterygoid fossa, which exhibited left orbital and intracranial invasion. On the 8th day after the first medical examination at our hospital, endoscopic sinus surgery (ESS) was performed, and a diagnosis of invasive fungal sinusitis with aspergillosis was made. We systemically administered the antifungal agent voriconazole (VRCZ) and treated the patient’s diabetes mellitus with insulin. The patient completely recovered without any visual acuity or ocular movement sequelae.
We reviewed the 37 cases of invasive fungal sinusitis reported from 2010 to 2018 in Japan including this case. In 28 cases (75.7%), the lesion extended to either the posterior ethmoid or sphenoid sinuses. Eighteen cases (48.6%) were accompanied by diabetes mellitus. In most cases, aspergillus was identified. Visual disturbance, restricted ocular movement, intraorbital invasion, and intracranial invasion were seen in 26 (70.3%), 21 (56.8%), 28 (75.7%), and 17 (45.9%) of the cases, respectively. The antifungal agent VRCZ was systemically administered in 33 (89.2%) of the cases. ESS, the Caldwell-Luc operation, and extensive surgery were performed in 32 (86.5%), 2 (5.4%), and 3 (8.1%) of the cases, respectively. The overall mortality rate was 19.9%, which was much lower than that in previously reported series.
Univariate regression analysis demonstrated statistically significant associations between mortality and diabetes mellitus (p = 0.037) or between mortality and intracranial invasion (p = 0.026). Multiple regression analysis was used to identify predictors of mortality. This analysis included diabetes mellitus, intracranial invasion, and visual disturbance. Only intracranial invasion was found to be significantly related to mortality (p = 0.047) as a predictor of mortality by multiple regression analysis.
Patients that experienced visual loss before treatment showed no post-treatment improvement in their visual acuity. Among the cases involving pre-treatment visual acuity of >0.01, visual acuity improved in 5 out of 6 of the patients (83.3%) after treatment. Ocular movement improved after treatment in 13 out of 17 of the patients (76.5%).
Prompt diagnosis via ESS and treatment with VRCZ are essential for treating invasive fungal sinusitis without sequelae.
Since Wormald et al. proposed the ‘building block concept,’ many studies have suggested that frontal sinus surgery should be performed following Wormald’s procedure. However, in Japan, little is known about the ability of otolaryngologists to perform frontal sinus surgery. In addition, new procedures in transnasal endoscopic surgery have been suggested in recent years, including a Draf type III endoscopic modified Lothrop procedure (EMLP) and endoscopic medial maxillectomy/endoscopic modified medial maxillectomy (EMM/EMMM). However, the prevalence of use of these new procedures is not clear. Therefore, we sent questionnaires on endoscopic maxillary and frontal sinus surgeries to otorhinolaryngologists who were associated with Osaka University. The results showed that in endoscopic sinus surgery (ESS), an operation on the frontal sinus was still considered to be the most difficult. Only 8% of doctors were able to perform endoscopic modified Lothrop procedure, and the most common reason why a hospital did not use endoscopic modified Lothrop procedure was that ‘no doctors can perform endoscopic modified Lothrop procedure.’ endoscopic medial maxillectomy/endoscopic modified medial maxillectomy was more commonly performed compared to endoscopic modified Lothrop procedure. For both endoscopic modified Lothrop procedure and endoscopic medial maxillectomy/endoscopic modified medial maxillectomy, doctors who could not perform these procedures stated that ‘I want to learn these procedures, but no there are no doctors who can teach them.’ This suggests that management of training for endoscopic modified Lothrop procedure and endoscopic medial maxillectomy/endoscopic modified medial maxillectomy is important.
Fibrous dysplasia is classified as either monostotic fibrous dysplasia or polyostotic fibrous dysplasia. It is most frequently found in facial bones where monostotic fibrous dysplasia is four times more frequent than polyostotic fibrous dysplasia. We report 2 cases of fibrous dysplasia in children. Case 1) A 10-year-old boy with a headache whose MRI showed a tumor on the left upper jaw visited our hospital. No physical findings other than a mild swelling of the left cheek were observed. CT findings showed a glassy bone thickening on both the left upper jaw sinus and lateral wall. For a definitive diagnosis, tissues were biopsied under general anesthesia, and the histopathological finding was fibrous dysplasia. Since no accumulation by bone scintigraphy was found except for the maxilla, the lesion was diagnosed as monostotic fibrous dysplasia. Case 2) A 12-year-old boy was seen by a local doctor who photographed the paranasal sinus X-P. The child was admitted to our hospital because of a left upper jaw bone thickening. As in case 1, there were no physical findings other than left cheek swelling. Based on in paranasal CT imaging, the bone thickening of the glass frill was observed on the skull base to the left face and lower jaw. Bone scintigraphy was found to accumulate in the thickened area of CT, but no accumulation was found in other sites. Since the pathological examination result of tissue collection under general anesthesia was fibrous dysplasia, it was diagnosed as polyostotic fibrous dysplasia. No findings other than cheek swelling were observed in both cases, and an increase in bone hypertrophy was not observed, so it is under observation.
Granulomatosis with polyangiitis (GPA) is characterized by glomerulonephritis and necrotizing, granulomatous vasculitis of the both the upper and lower respiratory tracts. Anti-neutrophil cytoplasmic antibodies (ANCAs) are frequently detectable in GPA patients. In the early stage of the disease, it is difficult to diagnose locally limited GPA based on both the pathological examination of a biopsy specimen and the detection of ANCAs. Thus, most patients are not diagnosed with GPA in the early stage, and the disease stage has the potential to progress unnecessarily.
Anti-moesin antibodies, one of the ANCAs, are reported to be detectable in some patients with myeloperoxidase (MPO) ANCA-associated vasculitis. Furthermore, the antibody titer is elevated in proportion to the renal dysfunction and systemic inflammation. One patient with granulomatous inflammation limited to the upper respiratory tract, that was strongly suspected to have GPA but was not definitively diagnosed because the disease condition did not meet the diagnostic criteria, could not receive any treatment for GPA for 2 years, and the disease progressed. We found that the anti-moesin antibody titer in this patient was elevated. Hence, remission induction therapy for GPA was initiated with both prednisolone and cyclophosphamide. Thereafter, the granuloma in the nose cavity quickly disappeared, and the patient completely recovered. Moreover, the GPA did not relapse for the duration of the maintenance therapy, and the serum anti-moesin antibody titer decreased to below the standard threshold and remained low after the induction therapy. Although further clinical studies are necessary, the anti-moesin antibody titer might be a promising diagnostic marker of early stage GPA.
A clinical study of patients with epistaxis requiring hospitalization was conducted among 206 patients (male 141, female 65; mean age 62.6 years) admitted to Oita University Hospital from January 1996 to April 2017.
Occurrence was more common in winter and spring than in summer; 103 cases (50.0%) were after-hour visits. There were 137 cases (66.5%) with some underlying disease. The most common of which was hypertension in 96 patients (46.6%). Forty-two patients (20.4%) were taking anticoagulants.
Bleeding sites were unidentifiable in 58 cases (27.2%), followed by posterior nasal in 57 cases (26.8%), upper nasal in 28 cases (13.1%), the middle turbinate and middle meatus in 23 cases (10.8%), Kiesselbach’s area in 17 cases (8.0%), the inferior turbinate and meatus in 14 cases (6.6%), the nasal septum excluding Kiesselbach’s area in 14 cases (6.6%), and other nasal sites in 2 cases (0.9%); some cases had multiple bleeding sites.
Main treatments were gauze packing and electrocoagulation. Recently, there is an increasing tendency to perform electrocoagulation and sphenopalatine artery ligation while the frequency of Bellocq’s tamponade or balloon tamponade has decreased. This change in treatment regimen is considered to have facilitated precise observation and treatment using nasal endoscopy.
Re-bleeding after hospitalization occurred in 30 cases (14.6%), of which 17 cases (56.7%) had a misidentified or unidentified bleeding site at admission. Re-bleeding may be caused by misidentification of the bleeding site, so nasal endoscopy is important to perform hemostasis under clear vision of the bleeding sites.