Objective: The spirogram is a common pulmonary function test frequently performed in otolaryngology, but has been only used to evaluate a patients’ surgical tolerance. Here, we evaluated if eosinophilic chronic rhinosinusitis (ECRS) is characterized by abnormalities in spirogram results.

Methods: Pulmonary function was measured in 46 patients with ECRS and 61 patients without who underwent sinus surgeries in our department. ECRS was diagnosed using the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic rhinosinusitis (JESREC) scoring system. In addition, smoking status, CT findings, and eosinophil percentage in peripheral blood were measured.

Results: The ECRS group showed a significant decrease in FEV1.0% and %V˙25 values compared with the non-ECRS group, but when patients with bronchial asthma (BA) were excluded from each group, these values were similar between the two groups. FEV1.0% was negatively correlated with the JESREC score (p = 0.04; r = −0.2). In ECRS diagnosis, FEV1.0 abnormality (<70) has a sensitivity of 15.2%, specificity of 91.8%, and positive likelihood ratio of 1.85, while %V˙25 abnormality (<80) has a sensitivity of 91.3%, specificity of 27.9%, and positive likelihood ratio of 1.27.

Conclusion: The ECRS group showed a significant reduction in FEV1.0% and %V˙25 values on preoperative spirograms, suggesting the effect of underlying BA. Abnormal FEV1.0 and %V˙25 were not useful for the preoperative diagnosis of ECRS because of a low positive likelihood ratio.

Cholesterol granulomas mainly occur in the middle ear in the otolaryngology region and are relatively rare in the paranasal sinuses. We experienced a case of cholesterol granuloma in the maxillary sinus. The patient was a 43-year-old female who had right cheek pain and purulent nasal discharge from about October 2015. She underwent surgery at another hospital in September 2016, but her symptoms persisted. She visited our hospital on X/Y/20XX. On MRI, a tumor-like lesion was detected in the right upper jaw sinus on a T1-weighted image. This lesion had high signal intensity on a T2-weighted image. On X + Feb Z, endoscopic modified medial maxillectomy was performed under general anesthesia. The polyp-like lesion was removed from the medial wall of the maxillary sinus. Pathological analysis indicated a hematoma under the epithelium of the mucosa, a large number of cholesterol crystals, and foreign body giant cells. These findings led to diagnosis of cholesterol granuloma. Postoperatively, the patient’s symptoms improved, and her sinus mucosa normalized.

【Introduction】Familiar odors differ according to cultural area; thus, olfactory examination differs among countries. The University of Pennsylvania smell identification test (UPSIT) was developed in the US, and it has been used globally. UPSIT consists of 40 odors, and the brief smell identification test (B-SIT) consists of 12 multicultural odors selected from UPSIT. The T&T olfactometry alone has been used for smell identification testing in Japan, and limited reports have shown that the T&T olfactometry can evaluate olfactory identification as accurately as overseas examination. The present study aimed to investigate whether the T&T olfactometry is as accurate as the B-SIT for evaluating olfactory identification.

【Material & Methods】In total, 41 patients who visited the Department of Otorhinolaryngology–Head and Neck Surgery at Osaka University Hospital between September 2017 and April 2018 underwent checkups using the B-SIT and T&T olfactometry and answered a self-administered odor questionnaire (SAOQ) and visual analogue scale (VAS) questionnaire. T&T olfactometry was underwent in open-ended format. We prospectively investigated whether the recognition threshold and detection threshold of the T&T olfactometry were correlated with the B-SIT, SAOQ, and VAS scores in the participants. Moreover, statistical analyses were performed using JMP Pro 13 software and correlations were examined using Spearman correlation coefficients and Regression coefficient, ANOVA.

【Results】The recognition threshold of the T&T olfactometry has a significant negative correlation with the B-SIT score. However, the detection threshold of the T&T olfactometry does not have a significant correlation with the B-SIT score. In subgroup analysis by disease, the recognition threshold of the T&T olfactometry has a significant negative correlation with the B-SIT score in the postviral olfactory disorder group.

【Conclusion】We found a significant negative correlation between the recognition threshold of the T&T olfactometry and the B-SIT score; thus, the T&T olfactometry was considered as accurate as the B-SIT for evaluating olfactory identification. This correlation is remarkable in postviral olfactory disorder group.

Juvenile angiofibroma (JA) is an uncommon, locally invasive, highly vascular and benign tumor that occurs in adolescent males. Established external surgical procedures for resection of JA include lateral rhinotomy, midfacial degloving, and transpalatal or infratemporal approaches; however, transnasal endoscopic approaches are increasingly being used because of advances in surgical techniques and endoscopic instrumentation. We report the case of a 14-year-old male who presented with left nasal obstruction and repeated epistaxis. A smooth reddish and hemorrhagic tumor was found in the left posterior nasal cavity. Computed tomography and magnetic resonance imaging showed a markedly enhanced tumor of approximately 40 mm in diameter that had obstructed the left posterior nasal cavity and nasopharynx, with occupancy of the pterygopalatine fossa. The case was diagnosed as Radkowski stage IIB. Preoperative embolization was performed to reduce tumor vascularity and improve visualization for surgical removal. Transnasal endoscopic surgery was used to resect the tumor en bloc after clipping the left maxillary artery. Intraoperative bleeding was 80 mL. To prevent recurrence, careful attention must be paid to tumor invasion into the Vidian canal. The postoperative course of our patient was uneventful, and there has been no evidence of recurrence for over one and a half years since surgery.

This study examined the work-life balance to determine the potential support needed for doctors, and especially for surgeons, in Japanese hospitals. Doctors were contacted and invited to participate in a survey on their work-life balance, working conditions, household burdens, satisfaction with their life and occupation, and health status. We were assisted in this process by alumni associations and local medical associations. A questionnaire was also distributed to medical students in their second and sixth years of higher education to assess changes in their awareness of work-life balance. Female doctors had a higher possibility of work-life conflict due to the burden of household chores and raising children, compared to male doctors. Surgeons reported more conflict caused by time constraints than other doctors. Significantly more female than male medical students asserted the importance of work-life balance. However, these gender differences decreased over the course of medical education. Assertions of gender-specific roles for household chores and raising children were affected by the home environment of the doctor. These results suggest that improvements are needed in work environments, including working conditions and hours, and in education at an early stage of medical school to ensure effective communication of issues surrounding work-life balance.

The three-dimensional (3D) anatomy of the nasal cavity and paranasal sinuses is difficult to grasp. However, the digitalization of imaging, including 3D computed tomography (CT), and the increased use of 3D images in clinical applications have gradually improved the understanding of these structures. In particular, beginners such as medical students seem to be unaware of the positional relationship between the nasal cavity and paranasal sinuses, and they often require an enormous amount of time to gain understanding of the nasal cavity and paranasal sinuses.

Recent improvements in computer technology and rapid prototyping technology have made it possible to accurately model a slice image obtained by CT or magnetic resonance imaging using a 3D printer. With the cooperation of the Nagasaki University Graduate School of Medical-Engineering Hybrid Professional Development Center, a full-scale 3D model of the organ was created from the actual paranasal sinus CT of the author. This nose and paranasal sinus model has become the new model used in the clinical education of medical students and has been used to improve the understanding. In this study, we report our experience using this model.

Currently, this model represents only the nasal cavity and paranasal sinuses, but it is hoped that in the future, a model will be created for the temporal bone, head and neck, and so forth. We also hope that further advances in technology and selection of model materials will enable the creation of models that are nearly identical to the actual human body, including soft tissues, blood vessels, and nerves.

A 5-year-old girl with right congenital nasolacrimal duct obstruction was treated with a lacrimal bougie and placement of a lacrimal endoscopy tube, but her condition did not improve. Her family requested treatment before entering elementary school and she underwent endoscopic dacryocystorhinostomy (E-DCR). After surgery, the symptoms resolved and there has been no recurrence. Congenital nasolacrimal duct obstruction affects 6–20% of newborns, but many cases heal naturally or with outpatient treatment. E-DCR has given good results in adults, but is harder to perform in children because of difficulties with surgery and the effects of bone growth. Thus, there is no consensus on surgical procedures and outcomes because E-DCR in children is rare. Continued follow up is planned in our case.

A 60-year-old male visited our hospital with complaints of rapid reduction in visual acuity and narrowing of the visual field. Upon MRI examination, a left maxillary sinus tumor was found. A biopsy was performed and the patient was diagnosed with small cell carcinoma. Anti-recoverin autoantibodies were also detected; thus, the ocular symptoms were thought to be due to cancer-associated retinopathy (CAR). The patient was treated with chemoradiotherapy and oral corticosteroids; however, while the tumor disappeared, his visual disorder remained. CAR is a rare, tumor-related syndrome and standard treatment has yet to be established. To our knowledge, this is the first case report of CAR associated with small cell carcinoma of the paranasal sinuses. When sudden visual impairment is seen in a patient with suspected malignancy, co-existence of CAR should be considered.

We report a case of sphenoid sinus inverted papilloma (IP) in an adolescent, which was removed by transnasal endoscopic surgery. The patient was a 13-year-old female who visited a nearby otolaryngologist with a chief complaint of nasal obstruction. Sinusitis was diagnosed, but did not improve, and the patient was referred to our department for detailed examination and treatment. A papillary tumor was found in the posterior portion of the right nasal cavity, and biopsy showed an inverted papilloma. Preoperative imaging led to diagnosis of an inverted papilloma with the base in the sphenoid sinus, and the decision was made to extract the tumor endoscopically. Since the patient was a child and development of the paranasal sinuses was immature, a transnasal septal approach was used. There has been no recurrence for more than 2 years after the operation. IP is the most common benign tumor of the nasal and paranasal sinuses. However, IP is more common in men in their 50’s and 60’s and rarely occurs in children. Endoscopic sinus surgery and nasal septal surgery are thought not to affect facial development in children, but there are few reports and minimally invasive surgery is recommended.

The anterior ethmoidal artery (AEA) arises from the ophthalmic artery and enters the paranasal cavity through the anterior ethmoidal canal. An accidental injury to the AEA during endoscopic sinus surgery (ESS) can cause bleeding and orbital hematoma. This should be avoided because it may result in severe complications such as blindness. The course of the AEA can mostly be determined on CT, and it is important to identify where the artery runs before an operation. Herein, we report a case of a 75-year-old man with an isolated AEA in an ethmoidal sinus cyst. The patient suffered from left ocular proptosis, ophthalmalgia and diplopia. CT and MRI revealed an ethmoid cyst without signs of cellulitis or abscess formation. A blood test showed elevations of leukocyte count and CRP, raising a concern of possible orbital complications. Therefore, we performed an emergency ESS. In view of flow-void sign at the preoperative MRI imaging, we suspected that AEA run through a cyst. During an ethmoid cyst fenestration with purulent drainage, we identified the AEA floating in the cyst, and thus determined to preserve it to complete the surgery. The patient recovered without any complications or postoperative bleeding. The location of the AEA can vary greatly among individuals, and this case underscores the importance of preoperative imaging to localize the AEA as a preventive measure against complications.

The human papillomavirus (HPV) has attracted much attention as a cause of sinonasal and oropharyngeal carcinoma. A deeper understanding of the overall incidence and clinicopathological profile is required for management of patients with HPV-related sinonasal carcinoma. Here, we report two cases of this disease.

Case 1: A 67-year-old man was referred to a hospital with epistaxis and a left nasal cavity tumor, which was diagnosed as sinonasal squamous cell carcinoma (SCC) (T3N0M0). Endoscopic sinus surgery (ESS) and lateral rhinotomy was performed and the tumor was completely resected. Postoperative histopathological examination revealed non-keratinized SCC. The tumor cells showed p16 immunopositivity on immunohistochemical (IHC) examination, and a polymerase chain reaction (PCR) assay revealed HPV 33.

Case 2: A 50-year-old man was referred to a hospital with epistaxis and a left nasal cavity tumor, which was diagnosed as sinonasal carcinoma (T2N0M0). ESS was performed and the tumor was completely resected. Postoperative histopathological examination revealed tumor cells showing partial differentiation into squamous epithelium, as well as features of salivary gland carcinoma. The tumor cells showed marked p16 immunopositivity on IHC examination. Based on these findings, HPV-related multiphenotypic sinonasal carcinoma (HMSC) was suspected. A PCR assay revealed HPV 56 and the patient was diagnosed with HMSC.

Patients with HPV-positive sinonasal SCC have a significantly higher overall survival rate than those with the HPV-negative disease; however, the sensitivity of chemotherapy and the correlation with p16 expression remain unclear. Therefore, currently, HPV-related sinonasal carcinoma is not accurately defined and its clinical behavior remains unknown. HMSC is a sinonasal tract tumor with features of both a surface-derived and salivary gland carcinoma, such as an adenoid cystic carcinoma, and has been newly classified as an HPV-positive sinonasal carcinoma. Further accumulation of cases of HPV-positive sinonasal carcinoma will be important to gain a deeper understanding of this disease.

Problems related to gauze are common in rhinological surgery, and these problems can place a burden on patients and medical staff. Here, we describe the effect of an intervention aimed at reducing gauze-related problems during surgery, based on the incidence before and after implementation of the intervention. In June 2019, a conference was held among all medical staff, including doctors and nurses, to discuss ways to improve gauze-related procedures. The incidence of gauze-related problems was retrospectively compared before and after this conference. January 2018 to May 2019 was defined as the pre-conference period and July 2019 to March 2020 as the post-conference period. During the pre-conference period, 214 nasal surgeries were performed, and problems with gauze occurred in 10 (4.6%). In 9 of these 10 cases, there was a mismatch in the gauze count: in 5 cases due to overlapping of gauze, and in 4 due to gauze falling on the floor or elsewhere. The former 5 cases of the count error occurred when two gauze pieces were placed on the same slot of the gauze counter. All 9 procedures were performed under general anesthesia. The rest of one case was accidental ingestion of the gauze under local anesthesia. After confirming the presence of foreign matter in the esophagus with radiography in this case, upper gastrointestinal endoscopy was performed urgently for gauze removal. During the post-conference period, the number of gauze-related problems markedly decreased to 1 (0.9%) in 112 surgeries. Therefore, we conclude that our intervention among medical staff to reduce gauze-related problems was successful.

A retrospective analysis was performed for 43 patients (32 males and 11 females, average age 61.7 years) with sinonasal inverted papilloma (IP) who underwent primary sinus surgery in our hospital from January 2012 to October 2018. Preoperative histopathology, origin of IP, extent of tumor spread, surgical procedure, treatment of tumor origin and recurrence were examined. The extent of tumor spread using the Krouse staging system was T1 (n = 4), T2 (n = 14), T3 (n = 22), and T4 (n = 3). Surgery was performed by endoscopic sinus surgery (ESS) alone (n = 28), ESS using drilling for bone excavation (n = 13), ESS with extranasal surgery (n = 2). For treating of tumor origin, we performed mucosal stripping alone (n = 9), drilling (n = 21) and cauterizing (n = 31). Mean postoperative observation period was 32.8 months (range 6 to 84 months), and the recurrence rate was 2.3% (1/43). To obtain satisfactory surgical outcomes, it is important to select the appropriate primary surgical procedures based on the preoperative histopathological diagnosis, origin of IP, and extent of tumor spread, and to completely remove the origin of IP.

Sinonasal inverted papilloma (SNIP), a benign tumor, demonstrates a high recurrence rate after surgery. Since the recurrence is not caused by tumor dissemination but by the tumor remnant, precise localization and excision of the originating site of a SNIP is essential. Therefore, it is important to precisely define prior to surgery the tumor margins with both computed tomography (CT) and magnetic resonance imaging (MRI).

It has been reported that the site of SNIP attachment can be defined prior to surgery based on either CT scans using bone osteitic changes as an indicator or MRI with convoluted cerebriform pattern (CCP)-based reverse tracing.

In this study, we defined the site of SNIP attachment mainly based on CT scans using bone osteitic changes as an indicator or MRI with convoluted CCP-based reverse tracing. It was possible to define the originating site of the tumor at a high rate using not only bone windows but also standard windows in the CT scans. We found that standard windows in the CT scans were effective. We present some cases and explain their usefulness.

Epithelial-myoepithelial carcinoma (EMC) is relatively rare among salivary gland tumors, and extremely rare in the nasal cavity. We report a case of EMC arising from the nasal cavity that was resected by an endoscopic approach. A 58-year old man visited our hospital with a complaint of repeated nasal bleeding. Computed tomography and magnetic resonance imaging revealed a tumor in the left nasal cavity. The biopsy specimen was hisotologically diagnosed as EMC and a tumor resection was performed by an endoscopic approach. The removed tumor was histologically diagnosed as EMC with an adequate surgical margin and no high-grade transformation. The patient has been free of recurrence during follow-up for three years without adjuvant therapy. This case was managed successfully with en block resection by an endoscopic approach and preservation of the nasal structure because the tumor was limited to the nasal cavity. We present the case with a review of the literature for clinical and histopathological findings, therapy and prognosis.

Introduction: The maintenance dose of allergens in sublingual immunotherapy varies depending on the agent, and adverse events increase with a higher dose of allergen and may affect treatment schedules. Subjects and Methods: Subjects who started treatment within one year from the first treated patient were followed in cases treated with Cedartolen^® (CT group, n = 207), Cedarcure^® (CC group, n = 69) and Miticure^® (MT group, n = 82). Adverse events and compliance with treatment were investigated. In the MT group, 87 cases that started treatment in the next year were also added to the study. Results: All subjects in the CT group were treated at the maximum maintenance dose. In the CC group, one subject (1.4%) received a temporarily reduced dose of allergen due to local sensory irritation, but the dose was subsequently returned to the maximum level; therefore, all subjects in the CC group ultimately received the maximum dose. In the MT group, 20 subjects (24.4%) had a reduced dose of allergen, mainly due to local edema. Of these 20 subjects, 18 later received the maximum dose, and 2 remained at the lower dose. In the MT group in the next year, the number of cases with a reduced allergen dose was halved. The rates of adverse events in the CT, CC and MT groups were 40.6%, 56.5% and 62.1%, respectively. Local edema and throat discomfort increased with the increased dose of allergen, and local edema in the MT group was high, with a rate of 41.5%. Local pruritus was more frequent in the CC and MT groups, and ear pruritus in the CC group was particularly high, at 21.7%. There were no severe adverse events and no treatment was required. Conclusions: As the dose of allergen increased, adverse events also increased, but all patients in the CC and CT groups were able to receive the maximum maintenance dose. In the MT group, temporary decreases in the allergen dose were required, mainly due to local edema. However, most patients eventually reached the maximum dose after proper up-dosing of allergen, and the number of dose reduction cases decreased as our experience with treatment increased.

A 60-year-old man with severe nasal congestion, rash and difficulty in eating due to oral mucosal erosion was referred to our medical center. At the first visit, he did not have a fever, but a blood test showed an intense inflammatory response. He had bleeding mucosal erosion of the inferior turbinate and nasal septum and purulent rhinorrhea; bleeding mucosal erosion of the soft palate and lips; and many cysts with red halos on the trunk and limbs. Colchicine 1 mg daily rapidly improved nasal and oral mucosal erosion and the inflammatory response. Contrary to this improvement, coughing and endotracheal nodules appeared and exacerbated, and bronchial wall thickening was found on computed tomography. These bronchial symptoms and findings resolved with an increase in colchicine to 1.5 mg daily. We have yet to establish a definite diagnosis, but we suspect MAGIC (Mouth and genital ulcers with inflamed cartilage) syndrome, which includes clinical manifestations of Behçet’s disease and relapsing polychondritis. We report the case along with relevant literature.

Nasal bone fracture is a common disease in otolaryngology, and is usually treated by closed reduction. In many cases, surgical outcomes are subjectively assessed by visual inspection by physicians. In recent years, ultrasonography (US) has been shown to be useful for diagnosis and objective surgical assessment of nasal bone fracture, but this approach is still not widespread. To examine this issue further, we conducted a questionnaire on management of nasal bone fracture among otolaryngologists at Osaka University Hospital and its related facilities. The questionnaire was sent to 121 doctors, and 61 responded. Of the respondents, 9 used US for assessment of outcomes of reduction procedures, but 50 did not perform an objective examination after reduction. The main reason was that ‘it is sufficient to assess reduction by visual inspection only’, which was given by 35 doctors, but 43 doctors (70%) also did not feel fully confident in their assessment of outcomes of reduction. In addition, 28 doctors (46%) did not know that US could be used in management of nasal bone fracture. We then conducted the questionnaire for doctors who used US in reduction of nasal bone fracture at Suita Municipal Hospital. Of the seven doctors that responded, 6 thought that US is useful for management of reduction of nasal bone fracture, and 4 had used US after transfer to another hospitals. We hope that increased awareness of evaluation of nasal fracture reduction using US will make physicians more confident in their ability to perform more accurate restorations.