Surgery for sinonasal malignant melanoma is referred to as primary treatment if complete removal is possible. Endoscopic endonasal surgery is now widely available for this purpose. We present a case of sinonasal malignant melanoma with skip lesions that was resected by endoscopic endonasal surgery. A 86-year-old male with recurrent epistaxis from a sinonasal tumor was referred to our department. Since a biopsy revealed sinonasal malignant melanoma in the right middle nasal meatus, we performed endoscopic endonasal surgery for tumor resection under general anesthesia. A postoperative endoscopic examination showed a skip lesion in the right maxillary sinus. Therefore, we performed endoscopic medial maxillectomy (EMM), and during the surgery we noticed another skip lesion in the right inferior meatus, which had not been identified preoperatively. Since the second operation, the patient has been followed for 3 years and 6 months without recurrence or metastasis.

Introduction: Central nervous system (CNS) infections due to filamentous basidiomycetes are extremely rare. We encountered a case of subdural abscess and hypertrophic pachymeningitis due to Schizophyllum commune that developed from sinusitis.

Case presentation: A 69-year-old woman visited our hospital with complaints of headache, right trigeminal neuralgia, dizziness, and right hearing loss. Magnetic resonance imaging revealed a mass in the right sphenoidal sinus and cerebellopontine angle. She initially underwent endoscopic sinus surgery (ESS), in which the mass lesion was removed from the right sphenoid sinus. The pathological specimens showed findings indicative of filamentous fungi on Grocott staining. However, her symptoms did not improve after ESS, and neuroendoscopic biopsy of intracranial lesions was performed as a secondary procedure. These specimens showed the same findings of filamentous fungi on Grocott staining. DNA sequencing of the sinus specimen revealed Schizophyllum as the causative pathogen, consistent with the diagnosis of fungal sinusitis and CNS infection. Treatment with liposomal amphotericin B drip infusion was started, but this resulted in no improvement and the treatment was switched to voriconazole drip infusion. Improvements in both radiological findings and symptoms were then observed. However, the symptoms exacerbated again when the trough level of voriconazole decreased. A subsequent increase in the voriconazole dose resulted in a higher trough level and improvement of symptoms.

Conclusions: This is a rare case report of CNS infection due to Schizophyllum. This case suggests that when these symptoms do not improve with liposomal amphotericin B, voriconazole administered at high trough levels can improve the symptoms.

Extraosseous plasmacytomas are localized plasma cell neoplasms that arise in tissues other than bone, and are most commonly located in the head and neck. The patient was a 83-year-old man who complained of left nasal bleeding and left nasal obstruction. He consulted a nearby doctor and a left nasal mass was discovered. A tumor with a smooth surface filled the left nasal cavity, and was observed from the left nasal cavity to the ethmoid sinus on sinus computed tomography (CT) and magnetic resonance imaging (MRI). Left nasal polypotomy under local anesthesia was performed for improvement of left nasal obstruction. A pathological examination revealed plasma cell neoplasms. However, blood M protein and urinary Bence-Jones protein were not present, and the bone marrow was found to be normal by biopsy; thus, findings of myeloma were not observed. The patient was diagnosed with extraosseous plasmacytoma and underwent left endoscopic sinus surgery under general anesthesia. The tumor had not infiltrated the surrounding tissues and was completely removed under visual inspection. However, the safety margin was not secured, which led to addition of radiotherapy after surgery. There has been no recurrence in two and a half years postoperatively. Since extraosseous plasmacytoma may shift to multiple myeloma after several years, there is a need to follow-up the patient regularly and carefully over a long period to monitor possible local recurrence and distant metastasis.

Glial heterotopia is an ectopic central nervous system that originates from the nasal cavity and subnasal area. Breathing in the first few months of life is dependent on nasal respiration, and a mass containing a glial heterotopia in the nose can trigger upper airway obstruction. In this study, we report a case of upper airway obstruction caused by glial heterotopia arising from the nasal cavity to the nasopharynx, which was corrected by endoscopic nasal surgery on the 25^th day of life.

The patient was female and less than 1-month-old. She began to have sleep apnea on day 11 of life, and a right nasal mass was noted on day 14 of life. On the 19^th day of life, she was sedated, and a contrast magnetic resonance imaging (MRI) was done, after which she was intubated because of worsening upper airway obstruction. The lesion was biopsied using a 2-mm bronchial fiber, and the diagnosis of glial heterotopia was confirmed by histopathological examination. Surgery was performed on the 25^th day of life. A 1.9-mm endoscope and a 2.9-mm microdebrider were used to resect the lesion. The anterior part of the lesion was solid, but the posterior part was cystic. The patient’s postoperative course was excellent. She was extubated on postoperative day 1 and discharged on postoperative day 6. At one year after surgery, there was no recurrence of upper airway obstruction due to enlargement of the lesion, and no evidence of collateral damage from surgery. Although complete resection of the lesion was not possible due to the location of the lesion, endoscopic nasal surgery preserved the function and improved upper airway obstruction.

MRI is a beneficial examination to decide a treatment plan for glial heterotopia. Small-diameter endoscopes and microdebriders are useful for endoscopic nasal surgery in children, including newborns, and are thought to be effective as a less invasive treatment for upper airway obstruction caused by benign diseases.

Nevoid basal cell carcinoma syndrome (NBCCS, Gorlin Syndrome) is a rare disease that was first reported by Gorlin in 1960. It is a syndrome characterized by abnormalities, such as palmar/plantar pits, calcification of the falx cerebri, and congenital malformations, as well as susceptibility to tumorigenesis in multiple basal cell carcinomas and odontogenic keratocysts of the jaw. The patient was a 14-year-old boy who had been aware of swelling of the left cheek one week before the first visit. He visited a nearby otolaryngology clinic and was referred to our hospital for further examination. He had a history of surgery for cleft lip and palate, and he exhibited swelling of the upper left maxilla, palmar pits, and hypertelorism of the orbit, which are characteristic of NBCCS. CT and MRI showed multiple cystic lesions in the upper and lower jawbones, and calcification of the falx cerebri. Based on the above findings, a definitive diagnosis of NBCCS was made, and surgery was performed on the keratocyst of the symptomatic upper left maxilla. The surgery was performed with endonasal endoscope in consideration of the preservation of postoperative function. First, the keratocyst was opened from the middle nasal meatus through the maxillary sinus, and a second hole was then created via the inferior nasal meatus. After the operation, the swelling was alleviated, the pressure symptoms disappeared, and the fenestration to the keratocyst was maintained. While NBCCS is a rare disease, it is important to understand the symptoms and diagnostic criteria of the disease for early diagnosis. In addition, for odontogenic keratocysts that occur in the maxilla, endoscopic endonasal surgery can improve the symptoms while preventing a decrease in the quality of life.

Inverted tooth refers to displacement of a tooth growing in the opposite direction to normal teeth. When an inverted tooth erupts in the nasal cavity or maxillary sinus, patients complain of nasal symptoms. Here, we report 5 cases of inverted tooth in the nasal cavity. Case 1: A 72 years-old male complained of a foul smell in his right nose. A foreign body was found in the bottom of the nasal cavity. The foreign body was removed and was found to be an inverted tooth. Case 2: A 31 years-old female complained of a sore throat and ear pain. A foreign body was found in the bottom of the right nasal cavity. The foreign body was removed by endoscopic surgery and found to be an inverted tooth. However, her original complaints were thought to be unconnected to the inverted tooth. Case 3: A 62 years-old female had an inverted tooth that was found during treatment of sinusitis. Since her sinusitis was cured completely, the inverted tooth was considered to be asymptomatic and observation was chosen without surgery. Case 4: A 9 years-old female had a foreign body in the right nasal cavity that was found in a medical examination. The foreign body was removed under general anesthesia and found to be an inverted tooth. Case 5: An 18 years-old male complained of facial pain, and a foreign body was found in the bottom of the right nasal cavity. The foreign body was removed under general anesthesia and found to be an inverted tooth. In previous reports, most cases of inverted teeth in the nasal cavity have been treated surgically. However, there are many asymptomatic cases and preoperative diagnosis of inverted tooth is not difficult. There are also some cases in which control of surgical pain is difficult and the tooth cannot be removed intranasally. Therefore, a risk/benefit assessment is important before deciding to perform surgery for an inverted tooth.

The Kiesselbach plexus is a common site of epistaxis, at which 70% of cases occur. It is relatively easy to cauterize this site using a bipolar electrode, but it is difficult to cauterize an epistaxis accurately at deep sites, due to anatomical factors. A malleable bipolar electrode is a device for electrocauterization that is mainly used in neurosurgery, but has recently also been used in the ear, nose and throat (ENT) field for transoral videolaryngoscopic surgery (TOVS). The malleable tip opens when the device is grasped by the hand, which makes it easy to approach hard-to-reach or tight spaces. We investigated the hemostatic effect on epistaxis using a malleable bipolar electrode in simple nasal cavity models based on data from 20 volenteers. Each bipolars electrode was inserted under an endoscope and the reachable area was plotted and visualized. We also report our clinical experience with two cases.