Eosinophilic chronic rhinosinusitis (ECRS) and bronchial asthma often occur concomitantly. As a simple and simultaneous treatment of both diseases, we describe a new technique for the nasal exhalation of inhaled corticosteroid (ICS). PIV-laser visualized inhaled HFA-134a-beclomethasone dipropionate (HFA-BDP) aerosol or Symbicort turbuhaler^® is still present in the exhaled breath because of its small particle size. This nasal exhalation technique of orally-inhaled ICS improved CT score and sense of smell in ECRS and then improved peripheral airway obstruction and symptoms in bronchial asthma. Thus, we demonstrated the utility of nasal exhalation of ICS for asthmatic patients with ECRS as a concurrent single therapy, which illustrates the new concept of “Airway Medicine”.

A retrospective study was conducted on 161 patients with peritonsillar abscess from July 2007 to June 2015 (111 males and 50 females; aged 11 to 86 years old, median age 41 years). All the patients were hospitalized and treated with drainage by incision for the abscess and intravenous administration of antibiotics. Out of the 161 patients, 83 (51.5%) were affected on the right side, 74 (46%) on the left and 4 (2.5%) on the bilateral. 137 (85.1%) patients were diagnosed as superior type and 24 (14.9%) as inferior type. In the blood test on the first day, number of white blood cells (WBC) ranged from 4600 to 26450 (median 12900) and C-reactive protein (CRP) ranged from 0.35 to 28.9 (median 7.98 mg/dl). Laryngeal edema was complicated in 35 (21.7%) of 161 patients. All the patients were treated with intravenous administration of either PIPC 2 g + CLDM 0.6 g (n = 74), ABPC/SBT 1.5 g + CLDM 0.6 g (n = 39), or ABPC/SBT 3 g (n = 31) twice a day. Decrease rates in WBC of patients with ABPC/SBT 1.5 g + CLDM 0.6 g or those with ABPC/SBT 3 g twice a day were significantly higher than those with PIPC 2 g + CLDM 0.6 g twice a day (p < 0.05). Age, CRP and percentage of laryngeal edema in the inferior type were significantly higher than those in the superior type (p < 0.05). Of the 24 patients of the inferior type of peritonsillar abscess, 12 (50%) patients cannot be drained with incision but cured with antibiotics and steroid. Four (16.7%) patients underwent abscess tonsillectomy under general anesthesia the next day after admission. These findings suggest that treatment with ABPC/SBT and drainage by incision is effective for peritonsillar abscess. The inferior type of peritonsillar abscess needs more intensive treatments including abscess tonsillectomy.

Here we report a case of second-stage pharyngeal syphilis. A 65-year-old male complained of increasing throat pain. Upon examination, his bilateral pharyngeal tonsils were swollen and showed erosion with a white-gray coating. Initially, we suspected that the patient had a mesopharyngeal tumor.

Serological tests showed high RPR, TPHA, and FTA-ABS titers. A tonsil biopsy, stained using the Warthin-Starry stain revealed a small number of spirochetes. No other symptoms were evident. On the basis of these findings, we diagnosed the patient with secondary pharyngeal syphilis. Notable improvement was evident following amoxicillin treatment.

The frequency of syphilis cases has been increasing over recent years. When diagnosing a patient with erosive tonsils, we recommend that physicians should consider the possibility of pharyngeal syphilis.

Aerosol medicine exhalation through the nose (ETN) is one of promising and comprehensive treatment methods for Eosinophilic Chronic Rhinosinusitis (ECRS) with asthma. In this treatment, the patient inhales aerosol of inhaled corticosteroid (ICS) medicine from mouth using portable inhaler. Then a part of the aerosol still floats and remains in upper airway. When the patient exhales inhaled air through the nose, the aerosol is effectively transported on the walls of middle meatus and olfactory fissure. The mechanism of how ETN improves ECRS with asthma is still controversial even though ETN gets a lot of attention as a treatment method for ECRS with asthma. This study performed Computational Fluid Dynamics (CFD) analysis for the transport phenomena of aerosol medicine during exhalation period in order to evaluate the curative effect of ETN numerically. A 75-years-old male, who had ECRS with asthma and a history of endoscopic sinus surgery was selected as an analysis case in this study. CT data. A 3D anatomically accurate patient-specific model was reconstructed from the data obtained using multidetector CT scanner with medical imaging software package. The entire series was loaded into the software, and then the nasal-pharynx airway was identified in each of the axial images based on predefined threshold of 250 Housfield units relative to the surrounding tissue. The nasal-pharynx airway model was exported into CFD meshing software package to generate discrete volume cells. This study used both a Euler-Lagrange particle transport model for aerosol transport and a Large Eddy Simulation model for complex intranasal turbulent flow, which are able to account for the transient transport of mass and turbulent energy, and consequently, provides highly accurate predictions of the amount of flow separation under adverse pressure gradients. This study assumed that the condition of exhaling flow rate through nose indicial set at 15 l/min and 30 l/min, respectively. As a result of CFD analysis, ETN formed impinging flow toward upper wall of nasopharynx, subsequently complex swirl and circulation flow in the nasopharynx region. In addition, main flow of ETN passed upper region of nasal cavity. Such the tendencies affected on aerosol transport characteristics; a part of aerosol particles moved into ethmoindal sinuses. Total aerosol deposition amount during ETN depended on flow rate of exhalation. This tendency was more remarkable on the upper wall of nasopharynx. On the other hand, deposition rate of aerosol on the ethmoidal sinuses did not appear strong correlation with flow rate of exhalation. These results imply that the phenomena of aerosol transport and deposition during ETN has non-stationary characteristics strongly. In past researches concerning CFD analysis for intranasal aerosol transport, steady-state turbulent flow model had been applied as CFD model. New finding of this study is that unsteady turbulent model, similar to the LES turbulent model adopted in this study, is needed in the further investigation for ETN.

Under normal circumstances, acute sinusitis is treated with antibiotics. If antibiotics are ineffective, endoscopic surgery provides an alternative therapy that only requires a short period of time to perform. We herein report a case of acute sinusitis that, for financial reasons, had a prolonged clinical course. A 52-year-old Japanese man, who was complaining of long-lasting left nasal obstruction and left facial swelling, was referred to our hospital. A computerized tomography scan revealed acute sinusitis and an old facial bone fracture that was causing facial cellulitis. Owing to financial issues, the patient refused endoscopic surgery as a treatment option. He was therefore treated with a long-term course of antibiotics. After 2 months had passed, the patient agreed to undergo an operation and endoscopic surgery was performed. The left maxillary sinus was filled with pus and was thus removed and thoroughly washed. Fungal masses were also observed in the sinus. After surgery, the patient recovered without any complications. This case suggests that it is important to be aware if a patient is reluctant to receive appropriate treatment for financial reasons. Preparations should be made for such instances, and social and private assistance, such as that from medical social workers, should be made available to the patient where possible.

We have previously reported that the number of children hospitalized due to intractable acute otitis media has recently shown a significant decrease. The introduction of pneumococcal vaccine seemed to be the most important factor. This study retrospectively reviewed the medical records of six children hospitalized due to acute mastoiditis at Chiba Children’s Hospital between 2007 and 2015. We also conducted comparisons with previously published data for children with intractable acute otitis media and acute mastoiditis from the same institution.

The six patients ranged in age from 11 to 39 months and were all boys. At the time of hospitalization, five patients presented with acute otitis media and acute mastoiditis in opposite ears. Administration of intravenous antibiotics and myringostomy were performed for all patients. Ventilation tube insertion was performed for one patient, and incisions for periosteal abscess were performed for two of the six patients. None required mastoidectomy. The period of hospitalization was seven to nine days. Streptococcus pneumoniae was isolated from three patients, with two showing penicillin intermediate-resistant S. pneumonia (PISP), and one showing penicillin-sensitive S. pneumonia (PSSP). Two of six patients had been vaccinated with pneumococcal conjugate vaccine. Serotype 7F (non-PCV-7) was isolated in one patient vaccinated with 7-valent pneumococcal conjugate vaccine (PCV-7), and non-PCV-13 serotype 35B was isolated in another patient vaccinated with PCV-13. The annual incidence of acute mastoiditis in our institution was 0.67 per year from 2007 to 2015, compared to 1.18 per year from 1990 to 2006. Significant changes were seen in the number of hospitalizations due to intractable acute otitis media, from 9.7 per year in 1990 to 2006 to 2.1 per year in 2007 to 2014. We found a smaller reduction in the number of children hospitalized due to acute mastoditis, compared to intractable acute otitis media cases. Although the introduction of PCV-13 could decrease the number of hospitalizations due to acute mastoiditis, continued surveillance is needed to monitor the changes of in pneumococcal susceptibility and serotype.

Background: Flexible laryngeal endoscopes are important tools in the everyday practice of Ear-Nose-Throat (ENT) departments. However, reprocessing procedures for endoscopes without suction or instrument channels (i.e., observation-only scopes) have not yet been standardized in Japan. The reprocessing process of endoscope consists of cleaning, disinfection, rinse, and storage. As for cleaning, the guideline of United Kingdom recommends the scopes to be cleaned using running water and neutral enzymatic detergents. However in Japan, recent questionnaire surveys show that the majority of ENT departments clean the scopes without detergents.

Therefore, we performed an ATP bioluminescence test for hygiene monitoring of the scopes to confirm the necessity of detergents.

Materials and methods: In two ENT clinics, 30 laryngoscopes were cleaned using each different protocols as follows.

Clinic A:

i.Wipe the insertion parts with alcohol gauze.

ii.Scrub the insertion parts with a sponge soaked with a neutral detergent for kitchen use.

iii.Scrub the insertion parts with a sponge soaked with an enzymatic detergent for endoscopes.

Clinic B:

i.Soak insertion parts in running water for a few seconds.

ii.Scrub the insertion parts with a sponge soaked with a neutral detergent for kitchen use.

iii.Scrub the insertion parts with a sponge soaked with an enzymatic detergent for endoscopes.

After soaking these scopes in the disinfectant and rinsing them with water, the ATP test was performed using a 3M™ Clean-Trace™ Luminometer. The measured ATP was expressed in relative light units (RLU). The result is defined as “pass” when the measured RLU was 20 and below, “fail” when the RLU was 21 and above. The ratio of pass/fail was compared between the different cleaning protocols.

Results: The ratio of pass/fail was as follows.

Clinic A: alcohol gauze, 14/18 (pass: 43.8%), neutral detergent for kitchen use, 24/6 (80%), enzymatic detergent for endoscopes, 29/1 (96.6%).

Clinic B: Running water, 21/9 (70%), neutral detergent for kitchen use: 25/5 (83%), enzymatic detergent for endoscopes, less soaking time 19/11 (63.3%), enough soaking time 30/0 (100%).

Conclusion: ATP hygiene monitoring shows, that for cleaning of laryngeal endoscopes, it is necessary to use enzymatic detergents with sufficient soaking time. The detergent for kitchen use is inadequate for cleaning endoscopes.

We report a case of outbreak with Methicillin-resistant Staphylococcus Aureus (MRSA) in our division. Seven patients were involved in this case. All patients were of head and neck cancer and their infection patterns showed two of different antimicrobial resistance. We executed three strategies to solve this problem. First, to survey a ratio of germ carrier, then second, to close the outbreak ward, and finally to reformulate the protocol for infection precaution. In these strategies, to formulate the infection precaution is extremely important, due to the high risk of infection for many immune failed patients, especially in the head and neck surgery. Infection expands by human factors, material factors, and environmental factors. In the new protocol for infection, we applied each countermeasures in form in conformity with CDC guidelines. We spent two months to control the outbreak with full cooperation of all over hospital. Time limitation, understaffing, and other problems such as the technical acquisition stand in the way for fixation of this protocol. It will be necessary to inspect problem and effectiveness of new protocol in future.

Patients with allergic rhinitis (AR) show augmented activity of the nitric oxide (NO) metabolism in the inferior turbinate mucosa, similar to that seen in bronchial asthma (BA). We believe that the measurement of nasal fractional exhaled NO (FeNO) can be used as a parameter for the diagnosis and classification of symptomatic AR patients. The purpose of this study was to assess whether nasal FeNO levels can be used as a reliable tool to evaluate the efficacy of intranasal steroids on allergic nasal symptoms.

A total of 10 symptomatic adult AR patients were enrolled in this prospective study. The patients received nasal steroids (fluticasone furoate once daily) for 2 months. Subjective symptoms were recorded on each visit according to the Japanese guidelines for AR. Oral and nasal FeNO measurements were carried out using a handheld electrochemical analyzer according to American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines.

The mean total nasal symptom score significantly decreased from an initial score of 4.4 to 2.38 after 2 months of treatment. The mean oral FeNO level remained unchanged compared with pretreatment baseline levels, however, the mean nasal FeNO level significantly decreased from an initial score of 47.6 ppb to 33.4 ppb after 2 months of treatment.

The attenuated nasal FeNO levels are likely due to the inhibition of inducible nitric oxide synthase isoform induced by corticosteroids, leading to diminished NO production in the inferior turbinate. Our results indicate that nasal FeNO measurement can server as an objective parameter for the diagnosis of AR and for monitoring the therapeutic effects of intranasal steroids.

Strains of Streptococcus pneumoniae or Haemophilus influenzae detected in the nasopharyngeal flora of 864 infant patients treated in our hospital for acute otitis media from 2011 to 2015 were examined. The frequency of detection of drug-resistant S. pneumoniae (DRSP) showed a significant decrease, from 48% in 2011–2012 to 32% in 2014–2015. The detection frequency of ampicillin (ABPC)-resistant H. influenzae remained constant at 77% in 2011–2012 and 76% in 2014–2015. The relevance of detection frequency of drug-resistant bacteria in patients <3 years of age and those ≥3 years of age is as follows: there was a significant difference in DRSP and no significant difference in ABPC-resistant H. influenzae from 2011–2012; no significant differences were noted in DRSP, and a significant difference was noted in ABPC-resistant H. influenzae from 2014–2015. The relevance of detection frequency of drug-resistant bacteria and group nursing are as follows: there was a significant difference in both types of bacteria from 2011–2012; no significant differences were noted in DRSP, and a significant difference was noted in ABPC-resistant H. influenzae from 2014–2015. The changes in the detection frequency of DRSP in the present study were due to administration of the pneumococcal vaccine; however, trends of drug-resistance among these bacteria must be closely monitored in the future.