Aerosol inhalation therapy plays a critical role in the treatment of asthma and chronic obstructive pulmonary disease (COPD). However, inadequate usage of inhaler results in poor therapeutic efficacy. Inhalers are broadly classified into 4 groups: dry powder inhalers (DPIs), pressurized metered dose inhalers (pMDIs), soft mist inhalers (SMIs), and nebulizer. Because the optimal inhalation procedure should ideally be changed with each inhaler, inhalation instructions for inhalation by healthcare professionals are desired in clinical practice. Here, we indicated the optimal inhalation instructions for each inhaler type as well as introduce the concept of clinical cooperation between hospital and community pharmacy with regard to inhalation therapy.
Descending necrotizing mediastinitis (DNM) occurs when an infection of the oral and throat region spreads rapidly in the mediastinal direction along the gap, due to the involvement of gravity, intrathoracic negative pressure. This is considered a fatal infection, particularly in the context of delayed diagnosis and treatment.
The main goal of treatment is early surgical drainage and debridement of necrotic tissue. In Endo’s Classification, Type IIa, in which the abscess cavity advances in the anterior mediastinum, and Type IIb, in which the abscess cavity advances in the posterior mediastinum, require mediastinal drainage. This procedure requires collaborative treatment with respiratory surgery. In type I, where the abscess cavity is confined to the superior mediastinum, cervical drainage is selected; however, there are cases in which mediastinitis occurs after surgery. Thus, even in Type I, advanceconferences with respiratory doctors are required.
Difficult cases are those with multiple abscess formation and those involving necrotizing fasciitis. In such cases, it may be necessary to extensively debride the fascia and muscles. In some cases, respiratory muscle is contracted with long-term intubation and respiratory rehabilitation is required; in other cases, aspiration may occur after surgery due to necrosis or contraction of the deglutition muscle, and long-term hospitalization is required. After the infection control is achieved, collaborative treatment is necessary with a speech-language-hearing therapist and a physical therapist, as soon as possible, in order to achieve early social reintegration.
Control of DNM is mainly based on surgery and antibiotic administration, and collaborative treatment with doctors in other departments is necessary. In the context of the patient’s return to society, collaboration with other specialties is important. By performing collaborative treatment with multiple specialties, it is possible to achieve total human medical care, with respect to saving the life of the patient and supporting the patient’s return to society.
It is recognized that malignant otitis externa is refractory to treatment and invasive otitis externa caused by pseudomonas aeruginosa and is often seen in immunocompromised elderly patients. Because inflammation deriving from temporal bone spreads to surrounding tissues along the skull base and may cause cranial nerve palsy, it has also been called skull base osteomyelitis (SBO).
Most SBO patients present with severe headache, however, levels of C-reactive protein, a marker of inflammatory reaction, are often low. The most important aspect in the diagnosis of SBO is to consider the differential diagnosis of malignant tumors, tuberculosis otitis media, and otitis media with ANCA-associated vasculitis. Diagnostic imaging of SBO is marked by cortical bone destruction in CT and the low intensity of bone marrow in T1 weighted-images of MRI. Standard treatment of SBO is intravenous administration of antibiotics for 6 to 8 weeks. Additional long-term antibiotic therapy may also be recommended. Because SBO often occurs in elderly patients, it is important to consider the general condition of the patient and the deterioration of daily life activities and cognitive function. Therefore, the collaboration of medical professionals such as pharmacists, nurses, physical therapists, and medical social workers is also necessary.
Conditions causing upper respiratory tract inflammation, including tonsillitis, dental infections, and airway foreign bodies, can result in cervical abscesses. Sternoclavicular septic arthritis is usually treated by orthopedic surgeons, but rarely causes cervical abscesses. We treated two patients with cervical abscesses. The first patient was a 69-year-old woman complaining of a 2-week history of fever and swelling on her left anterior thorax. Computed tomography (CT) showed an abscess extending from neck to mediastinum primarily around the sternoclavicular joint. Following admission, incision and drainage of the abscess with tracheostomy placement was performed under general anesthesia. Thirteen days after surgery, swelling reappeared on the patient’s anterior chest. At that time, osteomyelitis of the left clavicle and sternum was diagnosed by CT. Curettage of the clavicle was considered, but the patient refused treatment. Thirty days after surgery, an anterior cervical incision was made under local anesthesia, but there was no obvious sign of infection. The patient was discharged on postoperative day 50. The second patient was a 73-year-old woman complaining of a 1-week history of pain at the right sternal border. A right cervical abscess and mediastinal abscess were diagnosed by CT. After admission, incision and drainage was performed on both abscesses by a respiratory surgeon under general anesthesia. Osteomyelitis of the right clavicle was diagnosed by magnetic resonance imaging (MRI). The postoperative course was uneventful, and the patient was discharged on postoperative day 32. An abscess near the sternoclavicular joint requires evaluation with CT or MRI to differentiate cervical abscesses, mediastinal abscesses, and osteomyelitis. Sternoclavicular septic arthritis is rarely encountered in the routine practice of otolaryngology; however, it is essential to know that it can cause a cervical abscess. It is important to consider multidisciplinary approach during treatment based on the degree of inflammation.
The incidence of paranasal sinus mycosis has increased in recent years because of societal aging and the increasing number of diabetic patients. We report 38 cases of chronic noninvasive paranasal sinus mycosis treated with endoscopic sinus surgery between April 2011 and March 2018. The patients comprised of 13 men and 25 women aged 36 to 90 years, with a mean age of 70 years. In 16 of the 38 patients, no subjective symptoms were reported and paranasal sinus mycosis was found incidentally during imaging examination. Thirty-six patients had good prognosis, but 2 had a disease recurrence.
Acute sensorineural hearing loss is one of the frequently encountered diseases in otolaryngology, especially sudden deafness, which requires early intervention. There are a variety of treatments. The systemic administration of corticosteroids is currently common. However, corticosteroids have various side effects such as worsening of diabetes and elevation of blood pressure, and management is required for administration. The side effects also affect immunosuppression. The exacerbation of hepatitis B due to the administration of corticosteroid is described in immunosuppression/chemotherapy guidelines for hepatitis B countermeasures. We examined the presence or absence of the exacerbation of hepatitis B due to the treatment of hepatitis B positive cases in patients with acute sensory hearing loss who visited our hospital. The subject is an acute sensorineural hearing loss patient who presented at the Showa University Otolaryngology Department for 4 years from April 1, 2014, to March 31, 2018. Inoculation cases of hepatitis B virus vaccine were excluded. A total of 337 cases were included. Among them, 35 cases were positive for HBs antigen, HBs antibody, and HBc antibody. Regarding corticosteroid administration in any of the positive cases, PCR of serum HBV-DNA was carried out to confirm the amount of virus in the blood. There was no case detected at the initial inspection. There was no case where PCR was detected after one year. This was because the dose of corticosteroid used was not equal to or higher than the intermediate risk in the risk of the reactivation of hepatitis B. However, in this case, since there was no patient with detection sensitivity or higher in PCR originally and the number of cases per se was small, it is necessary to pay attention to the morbidity of HBV.
Flexible endoscopy is frequently used in daily clinical settings. As its disinfection is essential for safe use, in 2016, the first guidebook for infection control of flexible otolaryngology endoscopes was published by the Oto-Rhino-Laryngological Society of Japan (ORLJ). The purpose of the present study is to verify the method of cleaning and disinfection for endoscope that was described in the ORLJ guidebook.
We assessed the presence of bacteria on the flexible endoscopes from four institutions each time after performing endoscopy in 20 patients and that after cleaning and disinfection according to the method. Sampling was performed by wiping the surface of the operation and insertion parts of the endoscopy 10 times with a swab for bacteriological examination.
Before cleaning and disinfection, the detection rates of bacteria were 5% (1/20) and 70% (14/20) from the operation part and the insertion part of the endoscopy, respectively. After cleaning and disinfection, no bacteria were detected from either the operation part or the insertion part (0/20).
Although detection of parasites such as virus and chlamydia were impossible in the present study and further examinations were recommended, the method described in the guidebook was confirmed to be effective.
A 73-year-old woman complained of sore throat and consulted a general physician. A diagnosis of tonsillitis was made and she received oral then intravenous antibiotics. Once her symptoms improved, however, muffled voice and trismus developed. Peritonsillar abscess was suspected and she was referred to our department. No peritonsillar abscess was found but there was swelling of the left lateral band. Transnasal endoscopy showed prominent swelling of the lateral to posterior pharyngeal wall and also revealed pharyngeal stenosis. Enhanced computed tomography revealed a large abscess with ring-enhancement situated on the lateral pharyngeal wall to retropharyngeal space. Abscess opening under general anesthesia was planned. Trans oral intubation under video laryngoscope was first attempted, but failed due to trismus and airway stenosis. So, an awake intubation was finally performed under observation of bronchoscopy. After the mouth gag was set, left pharyngeal wall was swollen medially. The abscess was opened revealing yellowish pus. The cavity of the abscess was carefully explored and irrigated with saline. Finally, the nasal airway was settled for airway control. After the surgery, patient dramatically improved and oral intake was started the next day. She was uneventfully discharged hospital 8 days after surgery.
Tonsillitis and peri-tonsillar abscess are easily diagnosed by oral examination. On the other hand, swelling of lower part of lateral band is difficult by oral observation alone, but may cause lethal airway stenosis. Transnasal observation using an endoscope is useful for airway assessment caused by swelling of lateral band inflammation.
We report a case of 33-year-old female who was diagnosed as aseptic meningitis. The patient presented with fever, headache, and sore throat for several days. White coats were observed on her nasopharynx and aphthae were on her palatine- and lingual-tonsils, and the inflammatory response was high (white blood cells 9600/μl, CRP 9.18 mg/dl). She was diagnosed as acute pharyngitis. Sulbactam/ampicillin was administrated intravenously. Although local findings were improved, inflammatory response remained high and headache got worse. There was no abnormal findings in her brain CT. The level of consciousness was clear, and the neck stiffness and Kernig sign were negative. The lumbar puncture revealed increase in the number of cells (516/μl. Mononuclear cell 55%, polynuclear cell 45%), protein (39 mg/dl), and glucose (58 mg/dl, the blood glucose level was 92 mg/dl). Aseptic meningitis was suspected, and she was referred to the department of neurology. Considering the possibility of herpes simplex meningitis, acyclovir was administrated intravenously. Her headache improved promptly and she was discharged on the 14th day. Neither herpes simplex virus nor varicella zoster herpes virus was detected in the cerebrospinal fluid PCR test.
Aseptic meningitis is less likely to cause neurological manifestations except headache, such as conscious disturbance, than bacterial meningitis. Because only nonspecific symptoms are observed in many of the cases, lumbar puncture is required for diagnosis. Otherwise, it is often overlooked. When deteriorating headache and persisted pharyngitis were observed like in this case, the possibility of aseptic meningitis should be considered.
Malignant external otitis is a necrotizing external ear inflammation that develops in elderly patients with diabetes mellitus and is potentially fatal. However, treatment methods and evaluation of the therapeutic efficacy thereof are not yet established.
We report our experiences with 2 cases of malignant external otitis that presented at our hospital, to identify effective therapeutic regimens and introduce methods for evaluating the effectiveness thereof.
Case 1: A 74-year-old man presented with left otalgia, otorrhea, and facial nerve palsy. He was diagnosed with malignant external otitis and skull base osteomyelitis. Antibacterial medication was then administered intravenously but was discontinued on the 14th day because of side effects. On subsequent recurrence of symptoms, the patient was readmitted, and intravenous antibacterial therapy was resumed; however, he died.
Case 2: An 85-year-old man presented with left otalgia and otorrhea. He was also diagnosed with malignant external otitis and skull base osteomyelitis, and antibacterial medication was then administered intravenously. He did not experience side effects. Antibacterial administration was terminated 28 days after treatment initiation. A decrease in the erythrocyte sedimentation rate was used as the index for evaluating therapeutic effects. Currently, the patient is being treated with an oral antibiotic drug, and no recurrence of symptoms has been noted so far.
Based on our experiences, intravenous administration of antibacterial medication for 4 to 6 weeks, followed by oral antibiotic treatment for 6 to 12 months, can be considered an effective treatment for malignant external otitis.
In addition, erythrocyte sedimentation rate appears to be effective for evaluating the treatment efficacy.
Relapsing polychondritis (RP) is a rare systemic disease that leads to recurrent chondritis affecting the ear, nose, throat, and trachea. RP rarely presents with neurological symptoms, in only up to 3% of patients. A case of an 84-year-old woman who presented with left facial nerve palsy, left auricular swelling, and fever is reported. She was initially diagnosed as having Ramsay Hunt syndrome and treated with oral valacyclovir. However, the symptoms did not improve, and bilateral hearing loss and inspiratory stridor appeared. She was transferred to our hospital for further treatment. Subsequently, she developed not only bilateral sensorineural hearing loss, subglottic swelling, and scleritis, but also bilateral auricular swelling. She was finally diagnosed as having RP by Damiani’s criteria. Facial nerve palsy is not inconsistent with RP, although neurological symptoms in RP are rare. Oral prednisolone 40 mg/day improved the symptoms dramatically. She was misdiagnosed as having Ramsay Hunt syndrome because her unilateral facial nerve palsy and auricular swelling were on the same side, and the other auricle was not initially involved. There are few reports of RP with facial nerve palsy as the first symptom. Moreover, it is novel that, based on this report, it appears that RP and Ramsay Hunt syndrome need to be distinguished.
We need to consider RP when the patient presents with both facial nerve palsy and auricular swelling, even though facial nerve palsy in RP is rare.