Allergic rhinitis (AR) is a type I allergic disease of the nasal mucosa in response to inhaled aeroallergens and exhibits clinical symptoms such as watery rhinorrhea, nasal congestion, itching, and sneezing. Serum antigen-specific IgE (sIgE) measurements and a skin test (ST) against aeroallergens have been routinely employed to diagnose AR. Individuals exhibiting AR symptoms without a positive ST nor serum sIgE have been diagnosed as non-AR cases (NAR). However, the concept of local AR (LAR) has been advocated as a clinical entity mainly and initially in Europe. LAR is characterized by AR symptoms in the absence of systemic atopy assessed by ST or serum sIgE. The diagnosis of LAR should be rationally based on the detection of sIgE synthesis in nasal secretion or mucosa, and is now practically by a nasal allergen provocation test (NAPT). LAR is a stable phenotype and not an initial stage of conventional AR, it, however, shows moderate to severe nasal symptoms, remarkable impairment of QOL (quality of life) and rapid progression to symptomatic worsening. It should also be noted that LAR is often complicated with other atopic diseases such as atopic asthma and/or conventional AR. LAR complicated with AR is named dual Allergic Rhinitis (DAR). While no attention has been payed to LAR in Japan for long time, we reported the study about LAR cases in Japan this year, for the first time in Japan, based on our clinical and experimental investigation. According to our study, it is concluded that LAR is supposed to exist with the sensitization by house dust mite or Japanese cider pollen. This article is a review about LAR for clinical use containing its history, concept, diagnostic criteria and therapeutic choices in reference to recent publications updated including our published study.

　We report a rare case of isolated subcutaneous emphysema in the external auditory canal. The patient was a 15-year-old boy who presented with the complaint of his left ear pain/ear block when he sneezed or blew his nose. He visited a local clinic, was prescribed antibiotics, and showed temporary improvement. However, his condition deteriorated again, and he was referred to our department. Examination revealed narrowing of the left external ear canal caused by swelling of the skin covering the ear canal. CT revealed a large number of air bubbles in the subcutaneous tissue of the left external auditory canal, some defects and thinning of the bony wall of the left external ear, and the mastoid with poor growth on the left side as compared to the right side. We made the diagnosis of subcutaneous emphysema of the external auditory canal, and punctured and suctioned the swollen area and packed the ear canal with gauze; we also prescribed prophylactic antibiotics to prevent infection of the area.

　We speculate that the pressure in the middle ear cavity increased via the Eustachian tube when the patient sneezed or blew his nose, compressing the subcutaneous tissue in the external ear canal through the mastoid, eventually causing subcutaneous emphysema in the external auditory canal. We think that two major factors were operative in our case; one was the immaturity of the Eustachian tube in childhood which interfered with its protective effect against increase of the middle ear pressure and the other was the anatomical peculiarity of the left stunted mastoid cells with defects and thinning of the bony wall of the left external ear.

　We think that the initial treatment for such a case should be conservative, with follow-up under systemic/topical antibiotic therapy, puncture, suction and press with gauze on the swollen area. In patients presenting with recurrence despite the aforementioned measures, incision of the skin over the swollen area, insertion of an eardrum ventilation tube, or even reconstruction the external auditory canal bone wall may become necessary.

　Meningoencephalocele refers to herniation of the intracranial tissue, including the brain and/or meninges, through a defect in the skull base. Cranial meningoencephalocele is classified into occipital, frontal, ethmoidal, nasoorbital, and transsphenoidal types, according to the location of the defect. Transsphenoidal meningocele is rarely encountered. The patient was a 22-year-old man, with no previous history of nasal surgery or head trauma, who presented with a headache and underwent brain MRI. The MRI findings led to the suspicion of a sphenoidal pyocele. CT revealed a bone defect in the lateral wall of the sphenoidal sinus. We performed endoscopic sinus surgery to drain the pyocele and provide relief from the headache. However, after the operation, the patient developed high fever and developed a serous discharge from the sphenoid sinus. We corrected our diagnosis to transsphenoidal meningocele and performed reoperation. It was difficult to detect the point of the CSF leakage. We covered the defect in the sphenoid sinus with a fat graft obtained from the lower abdomen. A free mucus graft from the inferior turbinate was used to cover the fat graft. After 7 months, a brain MRI confirmed that the fat graft had not shrunk. Until the last follow-up at 3 years after the surgery, the patient had not developed any recurrence of the CSF leakage.

　Eagle syndrome is characterized by symptomatic elongation of the styloid process and/or calcification of the stylohyoid ligament. We report the case of a 70-year-old man with Eagle syndrome of the styloid process, who presented to us with the chief complaint of difficulty in swallowing. 3D-CT showed an elongated right stylohyoid process attached to the hyoid bone. We performed surgery to remove a part of the stylohyoid process, and the dysphagia improved immediately after the surgery. 3D-CT was effective for both diagnosis and selection of the appropriate therapeutic strategy. Surgical treatment could be considered as a therapeutic option for patients suffering from Eagle syndrome.

　Core-needle biopsy (CNB) and fine-needle aspiration biopsy (FNAB) are acceptably safe and reliable diagnostic procedures in the management of thyroid nodules/tumors. Herein, we report the case of a patient who developed a hematoma and pseudoaneurysm after CNB of the thyroid, and another of a patient who developed a transient thyroid swelling after FNAB of the thyroid gland. Case 1: A 56-year-old man with hypertension developed a hematoma immediately after CNB of the thyroid. Ultrasound-guided compression was attempted, and he returned home without exacerbation.

　However, five hours after the biopsy, he presented with a steadily enlarging neck swelling. Enhanced CT revealed a hematoma and a pseudoaneurysm arising from the superior thyroid artery. Emergency tracheostomy was carried out. Under antihypertensive therapy, the hematoma became smaller and the pseudoaneurysm was resolved. On day 8 after the procedure, he was transferred to another hospital for the treatment of papillary carcinoma of the thyroid with lymph node metastasis.

　Case 2: A 45-year-old man presented with a neck swelling, pain on swallowing, and breathlessness two hours after undergoing FNAB of the thyroid gland. Under the diagnosis transient thyroid swelling, cold packs and steroid drips were applied, and the neck swelling promptly resolved. He was discharged on the third day of hospitalization without recurrence.

　Neck swelling developing after needle biopsy should be distinguished between hematoma and transient thyroid swelling, and the risk of airway obstruction should be evaluated. It is important to obtain informed consent from patients and provide an explanation about the management of potential complications before performing any invasive examinations.

　Thyroid-like low-grade nasopharyngeal papillary adenocarcinoma is an extremely rare malignant tumor of nasopharyngeal mucosal epithelial origin. Histopathologically, it is an adenocarcinoma characterized by abnormal expression of thyroid transcription factors and papillary thyroid carcinoma-like morphology, but resembles a squamous cell carcinoma. There has been only one reported case domestically, while 24 cases have been reported from overseas. These reports mainly describe the histopathological findings and clinical progression of the cases, with scarce reference to the treatment strategies. Although the tumor is a low-grade carcinoma, the number of reported cases is extremely small, and no standard treatment has been established ; therefore, it remains unclear if it can be treated using the same treatment strategy as that adopted for the more common squamous cell carcinoma. We considered that this rare low-grade tumor could be resected in a minimally invasive manner by transnasal endoscopic surgery, even though the resection margins might be narrow. Herein, we report the resection plan and the procedure.