Paranasal mucocele is classified as primary and postoperative. Primary mucocele in the sphenoid sinus is rare. We experienced an extremely rare case with mucocele in the great wing of the sphenoid bone that was treated with an endoscopic endonasal transmaxillary approach. A 49-year-old male visited a neurosurgery clinic due to severe headache and vomiting, which was accompanied by right cheek pain and hypoesthesia. Magnetic resonance imaging (MRI) of the head showed a right sphenoid sinus lesion, and he was referred to our hospital. Computed tomography (CT) revealed a mucocele in the greater wing of the sphenoid bone. The patient underwent endoscopic transnasal transmaxillary surgery for marsupialization of the mucocele. After surgery, headache and cheek pain were immediately improved. Hypoesthesia of the right cheek gradually and completely improved within 7 months after surgery. After one year, there was no evidence of recurrent disease. This case shows that an endoscopic endonasal transmaxillary approach is an effective technique that gives a wide surgical field with a 0° endoscope.

Introduction: T&T olfactometry is a common smell identification test in Japan that is generally based on an open-ended questionnaire. However, use of an olfactory term table may make it easier to express an odor and judge the results. The University of Pennsylvania Smell Identification Test (UPSIT), which is widely used globally, includes 40 odors, while the Brief Smell Identification Test (B-SIT) uses 12 multicultural odors selected from the UPSIT. In the present study, we investigated the value of an olfactory term table by examining the correlation of T&T olfactometry using this table with results from the B-SIT.

Material and Methods: A total of 95 patients who visited the Department of Otorhinolaryngology–Head and Neck Surgery at Osaka University Hospital between September 2017 and May 2019 underwent check-ups using the B-SIT and T&T olfactometry. Of these patients, 54 who visited after July 2018 underwent T&T olfactometry using an olfactory term table. Thus, the 95 patients were categorized into olfactory term table usage and non-usage groups. Correlations of the recognition threshold in T&T olfactometry with B-SIT scores were examined in the two groups.

Results: The recognition threshold in the olfactory term table usage group correlated more strongly with the B-SIT score compared to that in the non-usage group. In subgroup analysis by disease, the difference in correlation coefficients was particularly large in idiopathic olfactory disorder group.

Conclusion: Use of an olfactory term table can more clearly reflect the degree of smell identification. Especially in idiopathic olfactory disorders, it is preferable to use it.

Meningoencephalocele is a protrusion of intracranial tissue, including meninges and brain tissue, through cranial bone defects. The frequency of meningoencephalocele at the skull base is reported to be 1 in 35,000–40,000, which is 1–10% of all meningocele cases. It is rare for meningoencephalocele to appear in the otorhinolaryngological field, and this condition may be diagnosed as a nasal cavity tumor, which may lead to a CSF fistula after surgery. Surgical resection is generally the treatment of choice for meningoencephalocele and is normally performed by craniotomy. In recent years, endoscopic resection and reconstruction have been increasingly performed at many institutions.

We report a case of a 52-year-old Japanese male who had loss of consciousness while working in China. Meningitis was diagnosed by a hospital in China. He was referred to our hospital immediately after returning to Japan, and a meningocele at the nasal cavity was suspected based on imaging diagnosis. We selected an endonasal endoscopic approach and asked for backup from a neurosurgeon for craniotomy in case this approach failed. First, a pedicled nasal septal flap was created and dropped into the choana to avoid mucosal damage during surgery. After proceeding with submucosal dissection and confirming the full extent of the mass, resection was performed at the skull base defect. The skull base was reconstructed with the tensor fasciae latae, fat tissue, and nasal septum cartilage, using the gasket seal technique. The pedicled nasal septum flap was used as the top layer to ensure blood flow to the reconstructed tissue of the skull base defect. Five-layered repair was performed to avoid CSF leak, and there has been no recurrence of meningoencephalocele or CSF leakage in 2 years of follow-up. This case shows that preoperative imaging diagnosis of meningoencephalocele is important to avoid a serious adverse event such as continuous CSF leak. With establishment of skull base reconstruction methods such as a gasket seal and the pedicled nasoseptal flap, less invasive endoscopic surgery is becoming a better choice for meningoencephalocele.

Introduction: The prevalence of allergic diseases, specifically food allergies, has increased in Japan. Pollen-food allergy syndrome (PFAS), caused by common pollen and fruit components, is a special type of food allergy that is often overlooked because most symptoms are confined to the oropharynx. Patients with PFAS can develop severe systemic symptoms such as anaphylaxis. This study examined the positive rates of food and inhaled allergens among outpatients visiting the Department of Otolaryngology at the Kansai Medical University General Hospital. Patients, who developed allergic symptoms of the oral and pharyngeal mucosa, were evaluated. The risk factors for oral allergy syndrome were determined.

Subjects: The study included 277 outpatients who underwent View39 allergy testing in the Department of Otolaryngology and Head and Neck Surgery.

Period: April 1, 2018, to April 30, 2019.

Method: We examined the sensitization rates of inhaled and food allergens (class ≥1 by ImmunoCAP), the correlation between inhaled allergens, the prevalence of oral allergy syndrome, blood eosinophil count and serum total immunoglobulin E (IgE) level at the time of the first visit, patient’s chief complaint and background characteristics, and background characteristics of patients who developed allergic symptoms of the oral and pharyngeal mucosa. Furthermore, logistic regression analysis was performed for prevalent and non-prevalent oral allergy syndromes to identify the inhaled allergens with a significant impact. These were based on the medical records obtained through an interview with the outpatient physician.

Results: Fifteen patients developed allergic symptoms of the oral and pharyngeal mucosa. Most patients had symptoms localized in the oropharynx. However, there were severe cases, involving systemic symptoms. The most common causative foods included apples, kiwis, and bananas. Overlapping sensitization to multiple inhalant pollen allergens was observed in multiple cases. A high rate of sensitization to the birch family was observed. The eosinophil count and total IgE level did not differ significantly between subjects with and without allergic symptoms of the oral and pharyngeal mucosa. Logistic regression analysis was performed on the prevalent and non-prevalent oral allergy syndromes to examine the odds ratio. The odds ratio was significantly higher for pollen allergens, especially the birch family. Many patients exhibited multiple sensitizations to other inhaled allergens as well.

Consideration: Sensitization to the birch family is important in developing oral allergy syndrome, and multiple sensitizations to other inhaled allergens were statistically impactful.

Conclusion: When evaluating cases involving birch sensitization and multiple sensitizations, documented by specific IgE antibodies, patients who developed oral allergy syndrome but did not report their symptoms should be interviewed regarding their oral and pharyngeal mucosal symptoms. Otorhinolaryngologists should be aware of this specific disease. A thorough interview, appropriate treatment, and patient guidance will lead to preventing minor symptoms and serious systemic symptoms.

Thyroid-like low grade nasopharyngeal papillary adenocarcinoma (TL-LGNPPA) is a rare malignant tumor that originates in the nasopharynx. Pathologically, the tumor shows papillary thyroid cancer-like findings of a thyroid transcription factor-1 (TTF-1)-positive and thyroglobulin (TG)-negative status. We report a case of nasopharyngeal papillary adenocarcinoma at the posterior end of the nasal septum.

A 50-year-old woman presented with sore throat in our department. Nasal endoscopy revealed a pedunculated tumor at the posterior end of the nasal septum. CT and MRI showed a pedunculated tumor without cervical lymph node swelling. Biopsy revealed a TL-LGNPPA that was TTF-1-positive and TG-negative. The tumor was endoscopically resected under general anesthesia without any complications. The pathological margin was negative. No recurrence or metastasis has been observed in one year and 6 months after the operation.

We experienced a case of a ethmoid-frontal sinus cyst that had formed due to ventilatory impairment caused by an obsolete medial orbital wall fracture. A 75-year-old woman presented to her local ophthalmologist with complaints of protruding eyeballs and left eye pain. She was referred to our ophthalmology department for a thorough examination because of decreased visual activity of the left eye. Imaging revealed a shadow in the frontal sinus, after which the patient was referred to our department for further workup. Subsequent imaging showed an obsolete left medial orbital wall fracture with associated orbital content deviation and a cystic lesion in the frontal sinus. Thus, formation of a secondary frontal sinusitis due to sinus drainage pathway obstruction of ethmoid-frontal sinus cyst was diagnosed, and endoscopic sinus surgery was performed. Postoperatively, sinus ventilation improved and the patient had a good outcome.

Orbital blowout fractures are caused by blunt trauma to the face and are often characterized by facial injury and visual dysfunction. However, some cases have minimal symptoms and no visual dysfunction, and thus, may go untreated. In such cases, there is a risk of development of sinusitis or a sinus cyst due to impaired ventilation of the sinuses caused by orbital content deviation or morphological changes in the sinuses.

Our experience suggests that even in cases of orbital blowout fractures with minimal visual dysfunction, surgical treatment may be considered if orbital content deviation is evident on imaging, as this may lead to ventilation problems in the sinuses.

Introduction: Olfactory disorder develops relatively early in patients with neurodegenerative diseases such as Alzheimer’s disease (AD). For verifying the usefulness of olfactory test as a screening tool for cognitive decline, we investigated the relationship between the olfactory identification test and Mini-Mental State Examination (MMSE) scores in community-dwelling participants of the Iwaki health promotion project. Since elderly people are not always conscious of olfactory dysfunction, we also examined the relationship of olfactory dysfunction awareness with cognitive decline.

Methods: We enrolled 844 participants (324 men and 520 women) in this study. Each participant was asked “How do you feel about the smell?”, and they answered either “good”, “average”, or “poor”. They also sniffed three odorants (India ink, cypress wood, and curry) in the odor stick identification test for Japanese. All the participants underwent MMSE. The MMSE scores were divided into two groups: the orientation and recall group and the remaining items group.

Results: In both men and women, the total MMSE scores significantly correlated with the simple olfactory identification test scores. When the MMSE scores were divided into two groups, the MMSE orientation and recall subset scores and the remaining 8 MMSE items’ scores, a significant correlation was observed only between the MMSE orientation and recall subset and olfactory identification test scores in both men and women. Regarding olfactory awareness, the participants with MMSE scores ≤27 tended to have a dissociation between olfactory awareness and the ability to identify odors.

Discussion: Mild cognitive impairment (MCI) is recognized as a precursor to AD. About 10% patients with MCI shift to AD annually, but early detection and early response to the MCI stage with AD may delay onset. In this study, a significant correlation was found between the brief odor identification test and MMSE orientation and recall subset scores. Many participants having MMSE scores of ≤27 were unaware of their impaired odor identification ability. Further study is needed for establishing a convenient olfactory test to detect early cognitive decline.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a disorder of impaired water excretion and hyponatremia with excess secretion of antidiuretic hormone (ADH). SIADH may be caused by intracranial disease, pulmonary disease, an ectopic ADH-producing tumor or medication. We report a case of SIADH caused by sphenoid sinusitis and pituitary abscess. The patient was a 75-year-old woman who presented with urinary incontinence, fecal incontinence and disturbance of consciousness. A blood test revealed prominent hyponatremia with a Na level of 103 mEq/L. Head CT showed right sphenoid sinusitis and osteolysis in the floor of the sella turcica and right orbital medial wall. Right sphenoid sinusitis and pituitary abscess were observed on MRI. The patient was admitted to our department on the same day with a diagnosis of SIADH caused by sphenoid sinusitis and pituitary abscess. Water restriction and intravenous supplementation were initiated by an endocrinologist. The serum Na level rose and clinical symptoms such as disturbance of consciousness improved day by day. Endoscopic sinus surgery was performed on the 7th day of hospitalization. There was pus in the sphenoid sinus and a perforation in the floor of the sella turcica, but no cerebrospinal fluid leakage. The operation was completed by closure of the perforated sella turcica with a free bone graft collected from the nasal septum. The postoperative course was good, serum Na returned to a normal level, and the clinical symptoms improved. The patient was discharged from hospital on the 14th postoperative day. In this case, inflammation spread from an osteolytic part of the floor of the sella turcica to the pituitary gland, and this seems to have caused SIADH. Thus, we suggest that SIADH should be considered in a case of hyponatremia with disturbance of consciousness, and that it is important to pay attention to SIADH caused by sphenoid sinusitis.

Most cases of fungal rhinosinusitis are non-invasive and have a good prognosis, but rare invasive cases may become severe and even fatal in immunocompromised patients. Here, we report the case of a 69-year-old woman with invasive fungal rhinosinusitis that developed during febrile neutropenia after chemotherapy for diffuse large B-cell lymphoma. The patient was referred to our department with right eye pain and full opacification of the right maxillary sinus on a CT scan. At the first visit, we suspected sinus mycosis and performed endoscopic maxillary antrostomy in an outpatient setting. Gauze packing was then inserted. When the gauze was removed on postoperative day (POD) 4, diffuse white mucosal lesions were observed in the right nasal cavity and fungal growth was suspected. On the following day, the mucosal lesions had turned black and necrotic, and had expanded rapidly in the right nasal cavity. A CT scan performed on POD 26 revealed swelling of the inferior rectus muscle and an increase in fatty tissues in the orbit, suggesting intraorbital invasion. Endoscopic sinus surgery was performed on POD 43. With continuous medical treatment there was no obvious exacerbation and nasal findings did not change significantly, although vertical movement dysfunction remained. The patient was transferred to another hospital on POD 98. Gauze packing after the first operation may have contributed to widespread fungal infiltration. This case shows the need for careful treatment and postoperative management in surgery performed during myelosuppression.

Human papillomavirus (HPV)-related multiphenotypic sinonasal carcinoma (HMSC) is a recently described distinct sinonasal tract tumor associated with infection by high-risk HPV subtypes. Despite histological features suggesting a high-grade malignant tumor, the clinical prognosis of HMSC is relatively good. Herein, we report a 37-year-old woman with HMSC who was referred to another hospital with symptoms of rhinorrhea and nasal obstruction. On examination, a tumor occupying the entire left nasal cavity was found and was histologically diagnosed as suggestive of HMSC. She was then referred to our hospital for radical treatment. MRI and PET/CT revealed a 4.0 cm expansile mass filling the left nasal cavity without invading any sinuses and surrounding bone structures, and no cervical lymph node metastases or distant lesions. In endoscopic tumor resection performed under general anesthesia, the origin of the tumor was identified as the nasal septum mucosa, with no adhesion or invasion to the middle and inferior turbinate mucosa. We then performed complete en bloc resection of the tumor with the nasal septum cartilage. Histopathological evaluation revealed sheet-like proliferation of atypical epithelial cells and nests with differentiation to myoepithelial cells. Differentiation to ductal formations, including eosinophilic cytoplasm, was also observed. High mitotic rates and necrosis were also present, but there were no findings of overt squamous differentiation. An immunohistochemical study indicated strong and diffuse p16 immunoreactivity, and in situ hybridization revealed high-risk HPV positivity. Given these findings, a diagnosis of HMSC was confirmed. Since the resection margins were negative for carcinoma and the tumor had not invaded the nasal septum cartilage, the patient received no additional postoperative treatment. There has been no evidence of local recurrences or distant metastasis for 12 months after the operation. However, these complications can occur many years after initial diagnosis, thus careful long-term follow-up is important.

The subjects were 16 patients with bronchial asthma and severe ECRS (eosinophilic chronic rhinosinusitis) who relapsed after endoscopic sinus surgery (ESS) and were treated with inhaled corticosteroids (ICS) exhaled through the nose, with subsequent addition of mepolizumab and then a switch to dupilumab. ECRS improved in 3 patients after ICS treatment, in 5 with mepolizumab, and in 8 with dupilumab. The maximum serum TARC level was significantly higher in the 8 patients who needed dupilumab than in the other 8 patients. Serum markers for IL-4/13 activation such as TARC may be useful for selection of appropriate management of relapsing severe ECRS with asthma.

Juvenile angiofibroma (JA) is a locally invasive, highly vascular and benign tumor that affects adolescent males. Radical resection has commonly been used as an external approach for treatment of JA for many years. However, transnasal endoscopic approaches have recently become widely used due to advances in equipment and surgical techniques. The endoscopic tri-port approach, which combines the techniques of transseptal access with crossing multiple incisions (TACMI) and the direct approach to the anterior and lateral parts of the maxillary sinus (DALMA), provides a wide surgical corridor with minimal invasion of the pterygopalatine fossa and does not require an external approach, including a Caldwell-Luc procedure. We experienced a case of JA that eroded the pterygopalatine fossa in a 17-year-old boy. Preoperative embolization was performed and the endoscopic tri-port approach was used for successful resection of the tumor en bloc after clipping of the maxillary artery.

Schwannoma in the nose and paranasal sinuses is rare and mostly originates from the nasal septum and ethomoidal sinus. However, it is often difficult to identify the origin of the nerve in these areas. Treatment of nasal schwannoma is performed by complete surgical excision and an endoscopic approach has become widely used in recent years. Here, we report two cases that were suspected to be vascular tumors preoperatively, but were then diagnosed as schwannomas postoperatively by the histopathological examination.

Meningoencephalocele is herniation of the meninges and brain through a defect in the skull. We report a case of meningoencephalocele of the sphenoid sinus that was operated on using a combined surgery.

The patient was a 73-year-old female in whom a soft tissue shadow with an 8-mm bone defect in the left sphenoid sinus was noticed on a Computed Tomography scan during follow-up of cerebral arteriovenous malformation at another hospital. The patient was referred to our department on suspicion of a left sphenoid sinus tumor. Head Magnetic Resonance Imaging revealed a continuous lesion from the left temporal lobe to the left sphenoid sinus, which gave a signal similar to that for the brain parenchyma and cerebrospinal fluid. Meningoencephalocele was diagnosed, and although the patient was asymptomatic, we decided to perform radical surgery based on the risk of cerebrospinal fluid leakage and meningitis.

The operation involved a combined surgery of endoscopic sinus surgery performed by a rhinologist and temporal craniotomy performed by a neurosurgeon. The sphenoid sinus was opened by endoscopic sinus surgery and a continuous meningoencephalocele was identified at a bony defect (Sternberg’s canal) in the superior wall of the lateral fossa of the sphenoid sinus. The meningoencephalocele was dissected at the middle cranial fossa and removed intranasally. The bony defect was reconstructed with multiple layers. The patient has had no sign of recurrence as of 1 year after surgery.

It has recently been reported that a meningoencephalocele can be removed by intranasal manipulation alone. However, in this case, we thought that it would be difficult to close the bony defect by intranasal manipulation alone based on following findings: intracranial pressure may have been increased due to AVM, the bone defect was relatively large, and we had no sufficient experience in endoscopic skull base surgery. Then, we chose a combined surgery for the safety purposes.

The Japanese Rhinologic Society has held a “Hands-on Seminar on Basic Research for Clinicians” led by the Society since 2014. The aims of the seminar are to raise the motivation and research skills for basic research among clinical otorhinolaryngologists, and to encourage interdisciplinary collaboration through research with universities. The attendees at the seminar are clinicians who are performing basic research in Japan. The seventh seminar was held at the 59th Annual Meeting of the Japanese Rhinologic Society (Tokyo), and focused on isolation of mononuclear cells from peripheral blood, nasal polyps, and tonsils. In contrast to past seminars, the seminar was held online and experimental procedures were shown by video because of the worldwide SARS-CoV-2 pandemic. A questionnaire completed by participants indicated a high level of satisfaction and a belief that the research seminar is needed. The seminar provides a great opportunity for rhinologists to obtain ideas for expansion of avenues for basic understanding of rhinologic disorders, and we believe that it should be continued for as long as possible.