Objective: To evaluate the effects of a virtual reality sinus simulator in medical education.

Methods: A total of 151 medical students undergoing bedside learning were included in the study over two years. Several instructors provided training based on a guidance manual. We examined the students’ knowledge of anatomy of the sinus and administered a questionnaire to determine their comprehension of surgical procedures involving the sinus after the training compared to the level of understanding before the training.

Results: The percentage of correct answers for anatomical knowledge of the sinus improved from 57.6% before the simulation to 88.8% after the simulation. Responses of “well understood” or “I think I understood” to questions on comprehension of surgical procedures involving the sinus were obtained from 82.6% of students for the maxillary sinus, 81.2% for the frontal sinus and 82.6% for the sphenoid sinus. Similarly, the response rates of “very high” or “high” to questions on interest in rhinology surgery and otorhinolaryngology were 95.7% and 94.2%, respectively.

Conclusion: Training using a virtual reality sinus simulator was useful to improve anatomical knowledge about the sinus and comprehension of surgical procedures involving the sinus, as well as to unify the training content because of standardization and customization of the surgical procedure. Thus, training using a virtual reality sinus simulator is a particularly effective tool in medical education for both medical students and instructors.

Correction of caudal septum deviation and open septorhinoplasty (OSRP) are currently performed in nasal septal surgery, in addition to traditional septoplasty. However, caudal septum deviation, dorsum septum deviation, and external nasal deformity are not defined by the Ministry of Health, Labor, and Welfare in reimbursement for nasal septum surgery. Reimbursement for rhinoplasty also does not include the concept of septoplasty. Thus, current reimbursement may not reflect the labor involved in advancement of nasal septal surgery. Therefore, we conducted a questionnaire survey on nasal septal surgery to evaluate the current situation. Valid responses were obtained from 75% of the centers surveyed. Both correction of caudal septum deviation and OSRP were performed in more than 60% of these centers. Correction of caudal septum deviation was performed by more experienced surgeons and required a significantly longer operating time compared to conventional septoplasty. OSRP was also performed by more experienced surgeons compared to septoplasty and required significantly more surgeons and a longer operating time compared to septoplasty and correction of caudal septum deviation.

Septoplasty using a hemitransfixion approach is an effective treatment for caudal septum deviation. The idea is to expose the caudal end of the nasal septal cartilage and adjust the cartilage to an appropriate shape and length. This method is useful; however, a delicate and careful technique is required to adjust the L-strut, which plays an important role in the strength of the nasal structure. The Modified Cutting and Suture Technique (MCAST) is a method for adjusting and refixing nasal septal cartilage, and is convenient and useful because it does not require transection of the anterior nasal spine or a septal batten graft. In this study, we investigated the usefulness of this procedure in 9 cases. CT examinations before and after surgery showed a significantly improved nasal cavity area ratio in all cases. There was also a significant improvement in the subjective symptom score. As an evaluation of external nasal deformity, a comparison of the nasolabial angle on CT before and after surgery showed no significant changes. These results suggest that MCAST is a simple and useful method for the hemitransfixion approach.

The Endoscopic Modified Lothrop Procedure (EMLP, Draf type III) is a surgical procedure in which the bilateral frontal sinuses are mono-cavitated and opened wide. Although EMLP is now regarded as a standard surgical procedure and many reports have shown its efficacy, postoperative stenosis of the opening of the unified frontal sinuses remains to be solved. In this study, we examined the causes of this stenosis based on evaluation of long-term outcomes of postoperative frontal sinus opening in patients who underwent EMLP at our hospital from September 2008 to October 2021. To prevent stenosis, in addition to removing as much bone as possible, oral steroids may be administered with the goal of suppressing adhesion and mucosal swelling through anti-inflammatory effects. Packing with chitin can also be used to promote wound healing and suppress adhesion in the early postoperative period. Thus, we compared the outcomes of patients who did and did not receive oral steroids and nasal packing with chitin. There were a total of 70 patients in the study. The mean age was 59 years and the mean observation period was 53 months (4 years and 5 months). There were 11 cases of stenosis (16%), of which 3 that involved obstruction underwent stenting (n = 2) and reoperation (n = 1). The mean time until the start of endoscopic stenosis was 98 days. Effects of oral steroids and packing with chitin to prevent stenosis could not be shown, but frontal sinusitis and a history of previous surgery were identified as risk factors for postoperative stenosis of the neofrontal ostium.

Inverted papilloma (IP) should be assumed to be present preoperatively in cases with suspicious findings, and requires surgical resection with a sufficient margin and base treatment. Here, we report a case of IP overlapping odontogenic maxillary sinusitis that required careful treatment.

A 62-year-old man was referred to our department due to lack of improvement on computed tomography (CT) of a shadow in the left maxillary sinus after tooth extraction and cleaning by our oral surgery department for left odontogenic maxillary sinusitis. CT showed soft tissue density localized in the left maxillary sinus, and conservative treatment with clarithromycin and carbocysteine was administered for three months; however, the shadow in the left maxillary sinus remained on CT and only showed mild improvement. IP was suspected based on localized bone thickening of the outer wall of the left maxillary sinus and the shape of the soft shadow, but biopsy was difficult because of the tumor localization. Contrast-enhanced magnetic resonance imaging (MRI) showed a convoluted cerebriform pattern, leading to a preoperative diagnosis of IP. Endoscopic modified medial maxillectomy (EMMM) was performed under nasal endoscopy, and the tumor was removed with a sufficient margin and base treatment. Postoperative pathological examination revealed a diagnosis of IP. At one year and five months postoperatively, the patient had no recurrence. These findings show that IP may be present in a case with a diagnosis of odontogenic maxillary sinusitis, and that IP should be assumed preoperatively based on suspicious findings, such as localized bone thickening. Biopsy may be difficult for IP confined to the maxillary sinus, and CT and MRI are useful for preoperative diagnosis.

We present two cases of successful hemostasis in patients with a re-enlarged pituitary adenoma who had intraoperative bleeding from the internal carotid artery during endoscopic endonasal pituitary surgery. Case 1 involved a woman in her sixties who suffered bleeding from the left internal carotid artery. The hemorrhage was controlled by applying direct pressure using cottonoids, followed by pieces of oxidized cellulose soaked in fibrinogen solution. Postoperative magnetic resonance angiography revealed a pseudoaneurysm, and the internal carotid artery was subsequently embolized with coils. Following a balloon occlusion test that indicated borderline ischemic tolerance, a superficial temporal-middle cerebral artery anastomosis was performed. Case 2 involved a man in his eighties who experienced bleeding from the left internal carotid artery during tumor removal using an ultrasonic surgical aspirator. Hemostasis was achieved by focal pressure using cottonoids, followed by insertion into the bleeding site of a crushed muscle patch taken from the thigh. Postoperative cerebral angiography identified a small pseudoaneurysm, and coil embolization of the internal carotid artery was performed without additional surgical procedures, as a balloon occlusion test showed ischemia tolerance. Both patients were discharged home without any additional neurological deficits. These cases show that initial control of bleeding from the internal carotid artery can be achieved through focal pressure using cottonoids, followed by compression hemostasis utilizing a crushed muscle patch. In cases in which a pseudoaneurysm arises at the site of injury, complete interruption of blood flow in the internal carotid artery through coil embolization should be immediately performed while considering the patient’s cerebral ischemic tolerance. This necessitates seamless collaboration among rhinologists, neurosurgeons, anesthesiologists, and nursing staff.

Jaw deformity causes bite disorder and facial deformity due to the abnormal size and morphology of the maxilla and/or mandible. The purpose of surgery for jaw deformity is to improve bite disorder and balance the maxilla and mandible. Such surgery is generally performed by an oral surgeon or plastic surgeon in Japan, while most otorhinolaryngologists are unfamiliar with jaw deformity surgery. The typical procedures used to correct jaw deformity are Le Fort I osteotomy for the maxilla and sagittal split mandibular osteotomy, intraoral vertical ramus osteotomy, or mentoplasty for the mandible. However, moving the maxilla upward may affect the morphology of the nasal cavity. Here, we report two cases of abnormal nasal cavity morphology after Le Fort I osteotomy. As both patients had anterior septal deviation and no change in facial appearance, we performed septoplasty via the hemitransfixion approach and bilateral submucosal turbinectomy. Nasal congestion improved postoperatively. Surgery that makes the maxilla move upward, such as Le Fort I osteotomy, carries a risk of abnormal nasal cavity morphology in which the nasal septum is separated from the anterior nasal spine during the operation. Thus, surgical techniques such as septoplasty via the hemitransfixion approach and open septorhinoplasty may be required. The appropriate procedure should be selected individually depending on the findings for each patient.

We report a case of a foreign body that penetrated the maxillary sinus and pterygopalatine fossa and reached the sphenoid bone. The patient was a 74-year-old woman who was brought to the emergency room with an iron gardening rod stuck in her right lip after falling at home. At the time of injury, she was conscious and had no symptoms other than mild temporal pain. A plain CT scan of the head showed the rod entering through the right upper lip, penetrating the anterior and posterior walls of the maxillary sinus, and reaching the greater wing of the sphenoid bone. Given the unknown shape of the tip of the rod and the risk of spinal fluid leakage, massive bleeding, or damage to the rod during removal, we attempted to remove the rod under clear vision. Under general anesthesia, the rod penetrating the maxillary sinus was confirmed by endoscopy. After the rod was removed, the rubber cap at the tip of the rod remained in the pterygopalatine fossa. Therefore, remaining fragments were removed endoscopically. The postoperative course was good, with no bleeding or infection at the wound site. Later, the removed rod was compared with a similar item to confirm that there was no damage. The pathway from the lip to the cranium contains the maxillary nerve, maxillary artery, and optic canal. Therefore, accurate assessment of collateral damage to these structures is crucial in selecting the appropriate treatment. In a case of a foreign body with an unknown tip shape, removal under clear vision and confirmation of no damage to the foreign body by comparison with a similar object after removal is recommended to reduce the risk of leaving fragments behind.

Ossifying fibroma (OF) is a benign fibrous bone neoplasm that is classified as a fibro-osseous lesion, similar to fibrous dysplasia. Here, we describe a rare case of OF in the frontal sinus. The patient was a 45-year-old woman who presented with redness and swelling extending from the right anterior forehead to the right eye, with significant antero-inferior deviation of the eyeball, complicated by diplopia. Computed tomography of the sinus revealed a mass lesion with mottled calcifications in the right frontal sinus, as well as a cystic lesion extending from the frontal sinus into the orbit. The patient did not consent to total resection via anterior skull base surgery. Therefore, after confirming the diagnosis through biopsy, the cystic lesion was removed from the temporal region by opening the lateral portion of the frontal bone, taking into consideration the location of the cyst and cosmetology. At present, at over 2 years since surgery, there has been no evidence of OF enlargement or recurrence of ocular symptoms or infection.

There are no widely accepted guidelines for treatment of OF, particularly in cases involving the frontal sinus, where surgical resection is limited by the complicated anatomy of the anterior skull base and orbital wall. However, in cases in which the tumor size does not rapidly increase, watchful follow-up is also a treatment option. The location and size of OF are crucial factors in determining the feasibility of complete resection. Moreover, a comprehensive understanding of the characteristics of fibro-osseous lesions, including OF, is required to formulate an individualized treatment plan in collaboration with doctors from other departments. Factors including surgical invasiveness and approaches and expected symptoms and risks should also be considered carefully.