Immunodeficiency in young children is one of the risk factors for intractable otitis media. In January 2015 a clinical IgG2 antibody titer test became covered by Japanese national health insurance, and it became possible to assess the immune system of pediatric patients. We have performed immunologic tests, including IgG2 antibody titer tests, on 30 intractable otitis media patients 0–2 years of age who were examined in our hospital since November 2014, and the results showed that 5 of them had low IgG2 titers. After treating 3 of them for a year, we concluded that they had indications for high-dose intravenous immunoglobulin (IVIG) therapy, and we performed the intravenous therapy in the pediatric department of a general hospital. When we did so, problems before and after treatment from the standpoint of physicians in private practice came to light, including deciding the criteria for indications, explaining about it to the parents/guardians to seek their understanding, performing as yet unperformed live vaccine immunizations and adjusting their timing, being in close touch with pediatricians on the hospital staff who perform the IVIG therapy, etc.

OBJECTIVE: The purpose of this study was to examine the effectiveness of tebipenem pivoxil (TBPM-PI) for treating pediatric acute otitis media, with particular interest in avoiding myringotomy.

METHODS: From a cohort of 245 patients with medium-grade pediatric acute otitis media who underwent diagnosis and treatment at our hospital according to the “Clinical practice guidelines for the diagnosis and management of acute otitis media (AOM) in children in Japan 2013”, 55 patients who required treatment at the third stage of the treatment algorithm were analyzed. All 55 patients provided consent for the study treatment. We administrated 1.2 mg/kg of TBPM-PI in twice-daily doses, once in the morning and evening. Treatment effectiveness was assessed on 3 ± 1 and 5 ± 1 days after the initial administration. In addition, when the severity score reached 0 points on 3 ± 1 days after the administration, the treatment was discontinued.

RESULTS: Severity scores significantly improved at 3 ± 1 and 5 ± 1 days after the TBPM-PI administration, as compared to baseline. In addition, 9 out of 55 patients (16.4%) scored 0 points at 3 ± 1 days after administration, and these patients were cured for a short period of time. At 5 ± 1 days after TBPM-PI administration, symptom improvement or cure, with a score of 0 or 2 (redness of tympanic membrane) was observed in 92.7% of cases (51/55). No adequate improvement was noted, even after the final TBPM-PI administration, in 4 out of 55 patients (7.3%), requiring a myringotomy.

CONCLUSION: TBPM-PI showed efficacy for the treatment of medium-grade acute pediatric otitis media, with more than 90% of these patients avoiding a myringotomy.

Nasal topical therapy is recommended instead of antibiotics to treat mild rhinosinusitis. A new saline aerosol has recently been introduced in Japan. The present study aimed to determine the effect of this aerosol in children. Thirty children (age 4–10 years) with rhinosinusitis that had persisted for at least two weeks were randomly assigned to an experimental group (saline; n = 15) that applied the aerosol for one second to each nostril twice daily for two weeks, or a control group (control; n = 15) that did not. Both groups received oral 50% carbocisteine and montelukast sodium for two weeks and then the effects on nasal symptoms, nasal patency and bacteria in the nasal cavity were compared between the groups. All patients in the saline group completed the aerosol therapy without complaint or adverse events. Nasal symptoms improved in 60% and 36% of the saline and control groups, respectively. The minimal cross-sectional area of the nasal airway was significantly wider after two weeks in the saline group. One and four participants in the control and aerosol groups, respectively, had no bacterial flora. These results suggest that rhinosinusitis in children can be effectively managed by daily nasal irrigation with the new aerosol. A nasal irrigation device should be selected considering nasal cavity stimulation and aerosol particle size.

A 59-year-old man with a history of diabetes mellitus had pain and swelling in the left side of the neck following dental treatment 1 week earlier. A diagnosis of neck cellulitis was suspected at a local clinic, and an antimicrobial agent was administered by intravenous drip infusion. The following day, the patient was referred to our department because of worsening symptoms. Physical findings at the initial presentation showed marked swelling around the left parotid gland, and laryngoscopy revealed edematous changes of the laryngeal surface of the epiglottis and the left arytenoid mucosa. Computed tomography on admission showed an increased density of subcutaneous adipose tissue in the area from the left cheek to the neck. The patient was admitted to the hospital due to the risk of airway obstruction. After admission, the administration of ampicillin/sulbactam was started. The following day, skin redness with blisters appeared on the face and trunk. According to the consultation with a dermatologist, the patient was admitted to a negative-pressure isolation room because of suspected varicella. Subsequently, varicella was definitively diagnosed based on increased levels of varicella-zoster virus immunoglobulin M. On hospital day 9, as crusts formed, the patient was discharged from the isolation room. On hospital day 13, treatment was discontinued due to the improvement in neck cellulitis. In the present case, as skin rash appeared after the start of treatment, other diseases such as drug eruption were initially suspected. However, the dermatologist diagnosed the patient with varicella based on the findings of skin and blood tests. The patient’s history of varicella was unknown. However, in cases of severe otolaryngological infections, as in the present case, clinicians should be aware of the possibility that adults are susceptible to contract varicella, particularly in patients who are in a somewhat immunocompromised state, such as those with concomitant diabetes.

Our case is a 71-year-old man with a history of diabetic renal failure who began hemodialysis treatment 5 years earlier. He visited an orthopedic surgeon 2 days before visiting our facility, and his condition was conservatively treated as cervical spondylolisthesis. After that, a disorientation disorder developed, and a computed tomography (CT) scan indicated an abscess on the left side of the posterior wall of the oropharynx. Only diffuse mild bulging was observed on the left side of the posterior wall of the oropharynx and no other abnormality was observed in the oral cavity and throat. A CT examination confirmed a complication in the spinal epidural abscess. A cerebrospinal fluid examination was performed, and bacterial meningitis was diagnosed. Blood glucose control and antibiotic drug administration were performed. However, because of the persistence of fever and poor improvement observed by CT and cerebrospinal fluid examinations, incisional drainage and tracheostomy were performed for the retropharyngeal abscess on the 12th day after admission. Because lower limb muscle weakness and low back pain remained and because a lumbar disc lesion and psoas abscess were recognized by magnetic resonance imaging, drainage was placed in the psoas abscess on the 17th day. The retropharyngeal abscess rapidly disappeared, and after treatment by orthopedic surgery, he was transferred for the purpose of rehabilitation on the 148th day.

The cause in this case was thought to be purulent spondylitis developing in the posterior portion of the throat and the psoas muscle, forming an abscess. In the case of retropharyngeal abscesses in elderly patients with impaired immune ability, it seems necessary to conduct a thorough examination and choose a treatment that will effectively control the inflammation from spreading to other sites.

Streptococcal toxic shock syndrome (STSS) is a severe invasive infection characterized by the sudden onset of shock, multi-organ failure, and high mortality. Here we present a patient with STSS caused by Streptococcus pyogenes (emm1/ST28), who was rescued by rapid treatment.

A previously healthy 64-year-old woman was referred to our hospital with cellulitis extending from the right neck to chest. CT scans revealed widespread subcutaneous inflammation, including the right cervical region, anterior thorax, and mediastinum. She soon developed septic shock and required tracheal intubation and vasopressor support in the intensive care unit. She failed to respond to intravenous antibiotics and vasopressor support, so emergency wide surgical debridement was performed. S. pyogenes with a highly mucoid morphology was detected in subcutaneous adipose tissue removed during the operation. Pathological examination revealed necrotizing soft-tissue infection. The patient was diagnosed with STSS and necrotizing soft-tissue infections, impaired renal function. Intravenous Meropenem (3 g/day) and Clindamycin (1800 mg/day) were initiated and she also received intravenous immunoglobulin. After S. pyogenes was isolated postoperatively, antibiotic therapy was changed to Ampicillin-sulbactam (9 g/day) and Clindamycin (1800 mg/day). She was transferred to the general ward on the 12th hospital day, and was discharged on the 53rd day. We characterized the isolate by emm typing and multilocus sequence typing (MLST). It was classified as the emm1/ST28 strain of S. pyogenes. emm1 is the predominant S. pyogenes genotype causing STSS in Japan and other countries, and it has a poor prognosis. ST28 also tends to cause severe infections. Although this patient had a poor prognostic infection according to genetic analysis, she was salvaged by rapid treatment.

Acute epiglottitis is a life-threatening disease. Patients with this condition need tracheotomy for safe management of the airway. This is a critical aspect because doctors are liable to face legal action in case they make a mistake in responding to acute epiglottitis. We report a case of severe swelling of the epiglottis, where the patient was on the verge of being choked because he did not allow us to perform a tracheostomy. The patient, a 55-year-old opera singer, had a sore throat and visited the emergency department of our hospital. He had swellings in the lower right tonsil and lingual face of the epiglottis. Based on laryngeal fiberscopy and CT imaging, we diagnosed his condition as acute epiglottitis accompanied by a right peritonsillar abscess. He was hospitalized and received an antibacterial medicine and a steroid through an intravenous drip. But after 10 hours, the patient’s condition deteriorated to respiratory distress and he developed a hot potato voice. Laryngeal fiberscopy showed a further inflammation of the epiglottis. We highly recommended an urgent tracheotomy to the patient, but he sternly denied the tracheotomy because he was worried about the impact of the procedure on his voice as an opera singer. After he signed a written informed consent that he would be responsible for all disadvantages incurred by not receiving a tracheotomy, we moved him to the ICU and completed the necessary preparations for an urgent tracheotomy if needed. Two head and neck doctors kept the patient under observation all night at the bedside. Fortunately, the swelling improved by the morning and he was discharged from the hospital seven days later.

In this case, the patient avoided choking without a tracheotomy despite severe swelling of the epiglottis. In this report, we refer to documents and consider the indications of tracheotomy, the characteristics of cases where conservative treatment was effective, and the measures to counter people who refuse a tracheotomy.

The numbers of foreign patients in Japan who cannot fully understand either Japanese or English have recently increased because of globalization. Communities and medical institutions that are responsible for regional medical care, especially for severe infections, need to be prepared for patients with communication difficulties.

We describe a Vietnamese male patient (age, 21 years) who presented with sudden neck swelling that was treated by emergency surgery. Whether the patient could understand the clinical course after surgery and during hospitalization was surveyed to determine appropriate medication for this patient, as well as others with different nationalities.

The patient spoke only Vietnamese. An abscess was confirmed from the dorsal side of the left submandibular gland to the anterior side of the left side of sternocleidomastoid muscle. Incision and drainage of the abscess, neck and tracheotomy proceeded under general anesthesia. Postoperative antibiotics improved his general status and the wound healed.

The survey results showed that the patient could not understand anything without an interpreter. We tried to communicate with him using a “conversation board” in addition to an “interpreter” while he was hospitalized, and found that he might not have understood the meaning of informed consent.

More patients of different nationalities are gradually presenting at our department. Therefore, a communication system even for languages of small countries should be established, especially for emergency situations.

This article introduces extracts of the updated parts of the “Clinical practice guidelines for the diagnosis and managements of acute otitis media in children in Japan 2018.”