Most patients with hereditary hemorrhagic telangiectasia (HHT) have nosebleeds, but otolaryngologists do not always treat these patients appropriately. HHT is understood to be a cause of nosebleeds, but few otorhinolaryngologists consider this disease during urgent treatment of epistaxis. Therefore, I will describe several tips for otolaryngologists to identify HHT and the essentials of dealing with nosebleeds.

HHT is often overlooked due to a lack of understanding of the diagnostic criteria, a lack of history taking, and inconsistent acquisition of endoscopic findings. The four Curaçao criteria are used for diagnosis. In patients with epistaxis, if two criteria in addition to epistaxis are satisfied, diagnosis of HHT is confirmed. A patient with recurrent epistaxis in whom vasodilatation is found via endoscopy fulfills two criteria, which meets the requirement for a suspected case. If a patient has a family history of nosebleeds or a history of pulmonary vascular embolization or cerebral infarction, HHT diagnosis is definite because three criteria are present. Thus, diagnosis of HHT is straightforward. Macroscopic vascular lesions vary widely and change, so if the lesions are mild in patients with severe nosebleeds, it is better to observe the lesions at different times.

Because most bleeding occurs from the anterior nasal mucosa, the thumb should be pressed against the alar for several minutes. If the bleeding does not stop, the otolaryngologist may stop the flow of blood by inserting calcium alginate loosely until the blood does not seep. At present, there is no definitive treatment for nosebleeds, so the aim of treatment is to prevent bleeding and alleviate symptoms. For this reason, strengthening the blood vessel wall and its surrounding connective tissue and reducing stimulation is recommended. The recommended first-line treatment is application of Vaseline to nostrils, timolol nose drops, oral tranexamic acid, and oral selective estrogen receptor modulators (SERMs) for peri- and postmenopausal women.

In the sports industry, exercise tests using equipment such as bicycle ergometers and treadmills have indicated that performance during sustained exercise, such as running a marathon, can be affected by nasal breathing disorders. Intermittent high-intensity exercise, such as playing soccer, consists of repeated instances of low-intensity exercise, which serve as rest periods, and high-intensity anaerobic exercise, but the effects of nasal breathing problems in this form of exercise have not been ascertained. In the current study, an artificial nasal obstruction was created and the effects of this obstruction on sustained exercise and intermittent high-intensity exercise were examined. To measure these effects under conditions similar to a sports setting, a 20-m shuttle run was used as sustained exercise and the yo-yo intermittent recovery test was chosen to represent intermittent high-intensity exercise. The number of shuttles and heart rate were measured, and a survey was conducted. The results revealed a significant decrease in the number of shuttles with forced nasal obstruction compared to normal conditions during both types of exercise. Similarly, the survey indicated that both exercises were significantly more strenuous with nasal obstruction. There were similar changes in heart rate over time during both exercises, but with nasal obstruction heart rate was lower immediately after conclusion of the exercise. The survey revealed that respiratory status was significantly worse with nasal obstruction. These findings suggest that nasal ventilation can affect sustained exercise and intermittent high-intensity exercise, and that it may affect exercise performance and mental state.

A T&T olfactometer (T&T) is commonly used as a standard olfactory test in Japan. An open essence (OE) test and the self-administered odor questionnaire (SAOQ) are also used in olfactory clinics, and are reported to be highly correlated with T&T results. We evaluated the correlation between each test performed before and 3 months after surgery in 105 patients with eosinophilic chronic rhinosinusitis (ECRS) who underwent surgical treatment. There were strong correlations between average T&T recognition thresholds and OE and SAOQ results. Criteria for improvement of olfactory dysfunction using OE and SAOQ were determined based on Japanese Rhinologic Society criteria for T&T. OE and SAOQ tended to classify more cases as cured and fewer in remission compared to T&T. The rates of improvement were 71.4% for T&T, 69.7% for OE, and 62.2% for SAOQ when cases were divided into cured/remission (improvement) and no change/aggravation (no improvement). The discrepancy rates for these classifications were 16.2% between T&T and OE, and 23.5% between T&T and SAOQ. These results indicate that the patient’s subjective evaluation and T&T results for the therapeutic effect may differ in some cases. This suggests the need to conduct an identification test to evaluate postoperative olfactory improvement.

Fungal sinusitis is a relatively uncommon clinical entity that may present as sinonasal inflammatory disease. Fungal sinusitis is classified as acute invasive fungal sinusitis, chronic invasive fungal sinusitis, chronic non-invasive fungal sinusitis (mycetoma), and allergic fungal rhinosinusitis, depending on the pathology. Mycetoma is the most common variant, is usually ipsilateral, and commonly involves the maxillary sinuses. Mycetoma is often refractory to non-surgical treatment, and consequently requires endoscopic sinus surgery (ESS) for treatment and to prevent development of invasive fungal sinusitis.

In the present study, we retrospectively investigated the backgrounds and radiological findings of patients with mycetoma of the maxillary sinus (fungus group) to evaluate the accuracy of preoperative diagnosis by comparison with patients diagnosed with ipsilateral chronic rhinosinusitis (CRS group). The posterior bony wall in the maxillary sinus measured on a CT scan was significantly thicker in the fungus group compared to the CRS group (p = 0.04), whereas there was no significant difference in anterior wall thickness between the two groups (p = 0.21). The incidence of opacification in the affected sinus on CT and that of low signal intensity of the mycetomatous mass on T2-weighted MRI were significantly higher in the fungus group compared to the CRS group (both p < 0.001). Diagnosis of mycetoma based on the low-intensity lesion on T2-weighted MRI (sensitivity 1, specificity 0.968) was more accurate than that using opacification on CT (sensitivity 0.688, specificity 0.839). The number of female patients with no demonstrable opacification on CT was significantly higher in the fungus group than in the CRS group.

These results indicate the usefulness of MRI for greater diagnostic accuracy for maxillary sinus mycetoma, especially in female patients.

Introduction: Posttraumatic olfactory dysfunction is caused by damage to the brain parenchyma, and amputation of the olfactory filaments due to head or facial trauma. The duration from injury to consultation has been suggested to be a prognostic factor, but only a few reports have studied this perspective.

Material & Methods: A total of 21 patients were diagnosed with posttraumatic olfactory dysfunction at the Department of Otorhinolaryngology-Head and Neck Surgery at Sakai City Medical Center between July 2015 and December 2020. The duration from injury to consultation and the reasons for a delay were investigated retrospectively.

Results: The duration ranged from 0 to 23 months, with a median of 5 months. Eight patients became aware of olfactory dysfunction more than 2 months after injury. In some cases, the time from awareness of olfactory dysfunction to consultation was prolonged because patients were left untreated in other departments after becoming aware of their condition.

Conclusion: Early detection of posttraumatic olfactory dysfunction can be achieved by recognition that patients with head and facial trauma may have olfactory dysfunction, despite the absence of symptoms. Creating awareness among otorhinolaryngologists and physicians of the pathophysiology of posttraumatic olfactory dysfunction in patients with head or facial trauma is likely to contribute to shortening the time from injury to consultation for these patients.

Maxillary osteotomy (Le Fort type I osteotomy) is used as a corrective surgery for jaw deformity. Some cases of nasal obstruction as a postoperative complication of Le Fort type I osteotomy have been reported in the field of maxillofacial surgery, but there are few cases in otorhinolaryngology.

A 26-year-old woman was diagnosed with jaw deformity in a dental department and underwent Le Fort I osteotomy in the plastic surgery department at our hospital. Nasal obstruction developed immediately after surgery and did not improve, and the patient was referred to our department. CT showed that the nasal septal cartilage was greatly deflected to the right and formed a high degree of lordosis as the maxilla had moved upward by 4 mm due to the osteotomy. Nasal septoplasty using the hemitransfixion approach and bilateral submucosal inferior turbinectomy were performed.

Le Fort type I osteotomy may cause nasal obstruction with nasal septum deviation because the vertical width of the nasal cavity is shortened due to the upward movement of the maxilla. There is a need to share information on this complication between maxillofacial surgeons and otolaryngologists.

Renal cell carcinoma is known to metastasize via blood flow, but metastasis of renal cell carcinoma to the nasal cavity and paranasal sinuses is rare. Here, we report a case of a 74-year-old male patient who presented with epistaxis for 2 months and buccal paresthesia for 5 months before his first visit to our clinic. He had a past medical history of right nephrectomy due to renal cell carcinoma and of multiple resections for metastatic renal cell carcinoma (i.e., pararenal lymph nodes on both sides and paracaval lymph nodes). Initially, hemostatic coagulation was achieved for right epistaxis and further physical examination revealed inferior turbinate swelling. Contrast-enhanced computed tomography revealed a mass involving the right maxillary sinus. Magnetic resonance imaging showed a heterogenous mass of 42 × 42 mm arising from the posterior wall of the maxillary sinus. Resection of this mass was performed under general anesthesia. An intraoperative frozen section did not suggest high grade malignancy. Therefore, whole tumor resection was performed endoscopically. The final pathology indicated renal cell carcinoma. The patient has had no signs of recurrence or metastasis for 22 months after surgery. A review of the literature shows that metastases to the nose and paranasal sinuses arise most commonly from the kidney. Our case suggests that a metastatic tumor should be considered if a patient with epistaxis has a history of malignant tumor.

Traumatic optic neuropathy (TON) is a rare disorder that can occur in association with head and face trauma. Optic nerve decompression and administration of steroids are common treatments. However, these approaches are controversial, and it is important to determine the choice and timing of introduction of treatment on an individual basis. In this report, we describe treatment of a case of TON with disturbance of consciousness at the time of injury.

A 36-year-old male was admitted to our emergency department with craniofacial trauma due to a traffic accident. The patient had disturbance of consciousness and his visual acuity was light perception. Computed tomography (CT) indicated a fracture in the right optic canal. Steroid pulse therapy was started immediately and endoscopic optic nerve decompression was performed on the fifth hospital day. Three months after surgery, visual field disturbance had improved and visual acuity had increased to 0.1 diopter.

Although CT showed TON with fracture in this case, surgery was delayed due to disturbance of consciousness. Despite performance of the surgery on the fifth day after injury, visual acuity improved. This suggests that in a case of TON with disturbance of consciousness, it may be more effective to prioritize steroid pulse therapy and wait for recovery of consciousness before surgical treatment.

Sarcoidosis is a rare granulomatous disease with an undetermined cause. Only 1% of cases have nasal cavity involvement. Patients with nasal sarcoidosis present with symptoms such as nasal obstruction, crust formation, epistaxis, olfactory disturbance, and nasolacrimal duct obstruction, which result in decreased quality of life. Here, we report a case of nasal sarcoidosis that required surgery for chronic rhinosinusitis and nasolacrimal duct obstruction.

The patient was a 39-year-old male who had previously been diagnosed with sarcoidosis at another hospital. He visited the Department of Ophthalmology and Otorhinolaryngology due to eye discharge, swelling of the dacryocyst area, and nasal obstruction. On inspection, the nasal mucosa was swollen with crusts and granulation. Sinusitis and nasolacrimal duct obstruction were also observed. Conservative treatment was thought unlikely to be effective, and thus, endoscopic sinus surgery (ESS) was selected as initial treatment. Postoperatively, oral steroids were used to control inflammation. Dacryocystorhinostomy was performed on day 10 after ESS. The nasolacrimal duct was obstructed distally on both sides due to strong adhesions, and especially in the left dacryocyst area, which was distal to the nasal cavity. Bicanalicular lacrimal stents were inserted after release of the adhesions. Postoperatively, the patient was treated with oral steroids, which were slowly tapered off. Two months postoperatively, the stents were removed. Crusts have continued to form in the nasal cavity, but there has been no recurrence of sinusitis or nasolacrimal duct obstruction. However, careful follow-up is continuing because such recurrence remains likely due to granulation and crust formation secondary to sarcoidosis.