Sleep breath disorder （SBD） in children is a complicated condition that ranges from snoring to obstructive sleep apnea （OSA）. It includes various respiratory and ventilatory conditions that are difficult to assess solely by apnea hypopnea index （AHI） alone. Symptoms and complaints vary with age. SBD affects not only physical development but also mental development. Adenotonsillar hypertrophy and craniofacial structure cause predisposition to OSA. In addition to anatomic factors, the cause of OSA is predicated on neuromuscular reactivity, arousal threshold and ventilatory control. Because of the possibility of spontaneous improvement, intranasal steroids may ameliorate mild OSAS, but follow-up is needed. For severe cases or cases with complications, appropriate treatment based on the cause and pathophysiology is necessary in addition to palatine tonsillectomy and adenoidectomy

View full abstract

Facial nerve neurilemmoma of the parotid gland is relatively rare. Non-surgical treatment methods, such as observation, are preferred over surgery for esthetic reasons. In our experience, an increasing number of cases have been developing permanent facial palsy following intracapsular resection for this type of tumor. In order to elucidate its cause, we investigated the risk factors for this complication.
We enrolled seven patients who underwent intracapsular resection for facial nerve neurilemmoma of the parotid gland at our center between 2013 and 2019, and evaluated their age, sex, maximum tumor diameter, tumor shape, condition inside the tumor, tumor position during surgery, and preoperative and postoperative facial palsy.
The results indicated that the protruding, solid, and main trunk tumor types were associated with a high risk of permanent facial palsy. On the contrary, the flat, solid and cystic, and peripheral tumor types were associated with a relatively low risk of permanent facial palsy. These findings suggest that evaluating the risk factors in each patient would contribute to effective treatment planning and informed decision-making.

View full abstract

Objective: The Japanese society of OtoRhinoLaryngology-Head and Neck Surgery （JORL-HNS） issued guid­ance on tracheostomy for suspected or confirmed cases of severe acute respiratory coronavirus 2 （SARS-CoV-2） infection in April 2020. To avoid the generation of aerosols, it is necessary to change the tracheostomy procedure. Our medical office performs tracheostomies according to the JORL-HNS guidance because we perform tracheostomies smoothly using an unusual procedure. We verified the significance of the change in the procedure.
Methods: We performed 48 tracheostomies from April to December 2020. Twenty-three of them, excluding cases of head and neck surgery and local anesthesia, were performed according to the JORL-HNS guidance on tracheostomy. We surveyed 17 staff members at our medical office about the procedure change. Preoperative PCR tests were negative multiple times in all cases. We performed the procedure using standard personal protective equipment under general anesthesia. The surgeons were not always the same. In addition, we compared the average operation time during the study period after the procedure change with that during the previous year.
Results: The average operation time was longer and the physical and mental burden on operators increased with the procedure change. Cooperation with other medical workers, such as anesthesiologists and nurses was important, and they all understood the new procedure well. Everyone in our medical office thought the procedure change was meaningful.
Conclusion: Since there are likely to be a number of SARS-CoV-2-positive patients requiring tracheostomy in the future, and SARS-CoV-2 PCR tests can give false-negative results, we need to master the tracheostomy procedure recommended by the JORL-HNS guidance. Our survey suggests that the procedure change is meaningful.

View full abstract

Hypopharyngeal foreign bodies are one of the most common diseases encountered in the daily clinical practice of otolaryngology. In the elderly, PTP sheets and dentures have been the most common non-edible hypopharyngeal foreign bodies. However, there have been no reports of emergency surgery for securing airways due to accidental ingestion of a nasal splint, which does not normally enter the oral cavity. In the present study, we experienced a case of emergency tracheostomy and hypopharyngeal foreign body removal for severe laryngeal edema caused by an errant nasal splint. In the case of rapid respiratory failure in the elderly, it is essential to consider the possibility of ingestion of foreign bodies that do not usually have the opportunity to enter the mouth.

View full abstract

Nasopharyngeal tuberculosis is a rare type of extrapulmonary tuberculosis that accounts for approximately 0.2% of all tuberculosis cases worldwide. We herein report a case of nasopharyngeal tuberculosis in a patient who presented with a cough and sore throat. Nasopharyngeal endoscopy revealed a mucosal lesion with a white coating in the left fossa of Rosenmüller. The patient was diagnosed with nasopharyngeal tuberculosis based on positive results from staining for acid-fast bacilli in the pharyngeal mucosa, and on a polymerase chain reaction （PCR） assay for Mycobacterium in sputum. Chest radiography revealed pulmonary tuberculosis; thus, multiple anti-tuberculosis drug therapy was initiated. The nasopharyngeal mucosal lesion was no longer observed on nasopharyngeal endoscopy after 6 weeks of multi-drug therapy.
The symptoms of nasopharyngeal tuberculosis vary and can include cough, cervical lymphadenopathy, otorrhea, sore throat, nasal congestion, weight loss, and fever. Two main types of manifestations of this form of tuberculosis observed on nasopharyngeal endoscopy are mass lesions and ulcerative lesions, which mimic nasopharyngeal malignancies. Diagnosing nasopharyngeal tuberculosis definitively can be difficult because of the lack of specific findings and symptoms, and several examination modalities are usually needed to confirm the initial diagnosis. Nasopharyngeal tuberculosis should be considered as a differential diagnosis of mucosal lesions with a white coating in the nasopharynx. As the sensitivity of microbiological culture is relatively low, repeated pathological examinations and PCR assays are essential for early and appropriate diagnosis. In conjunction with this difficulty in diagnosing nasopharyngeal tuberculosis, special attention must be paid to protect healthcare workers from occupational exposure. Rapid identification of staff with potential infection and application of routine screening tests are key to preventing secondary infections.

View full abstract

Sialoendoscopy has enabled us to remove parotid stones without facial incision. However, the success rate of removing stones by sialoendoscopy depends on their size and localization. We report a case of multiple sialoliths in Stensen’s duct and parotid gland, which were removed by a combination of sialendoscope with a small buccal skin incision. A 60-year-old man was diagnosed with multiple parotid salivary stones on the right side. The stones were 6–8mm in size, one in Stensen’s duct and the other two in the parotid gland. A small incision was made in the buccal skin, and one of the stones was removed. A sialendoscope was inserted through the excised site of Stensen’s duct and then the remaining stones were removed. The combination of sialendoscope with a small incision was useful for removing multiple parotid salivary stones by minimally invasive surgery.

View full abstract

Allergic rhinitis is one of the most common allergic diseases in Japan. In particular, Japanese cedar pollinosis has a prevalence of about 40% and is an important therapeutic target. Allergic rhinitis often causes pharyngeal symptoms such as itching of the epipharynx. In recent years, there have been many reports on the therapeutic effect of epipharyngeal abrasive therapy （EAT） on chronic epipharyngitis. EAT has been reported to be effective not only for post-nasal drip, pharyngeal discomfort, chronic cough, and headache, which are symptoms caused by chronic epipharyngitis itself, but also for allergic diseases. However, unclear points remain regarding the mechanism by which EAT is effective for allergic diseases. Here, we report one case in which EAT was effective for epipharyngeal allergy due to Japanese cedar pollinosis, and discuss its mechanism based on histopathological findings. A 34-year-old man with Japanese cedar pollinosis was aware of itching epipharyngitis during the annual pollen dispersal season. Continuous administration of EAT improved chronic epipharyngitis and suppressed epipharyngeal allergy due to hay fever. We consider that squamous metaplasia of the ciliated epithelium and formation of fibrous interstitium just below the mucosal epithelium are the mechanisms of the therapeutic effect of EAT on epipharyngeal allergies.

View full abstract

Introduction: Ultrasonography is a non-invasive method for the diagnosis of sialolithiasis. However, salivary stones in Wharton’s duct are usually too small to detect with ultrasonography. In this study, we examined the potential usefulness of transoral ultrasonography to detect salivary duct stones.
Methods: Transoral ultrasonography examination was performed on patients diagnosed with submandibular gland sialolithiasis.
Results: The hockey-stick probe enabled us to detect salivary stones transorally. The transoral sonography could detect salivary stones well, especially when the stones were located in the middle of Wharton’s duct. In two cases, transoral ultrasonography helped us to detect salivary stones in Wharton’s duct during operation.
Conclusion: For submandibular gland sialolithiasis, transoral ultrasonography with the hockey-stick probe was useful to identify salivary stones in Wharton’s duct.

View full abstract

We experienced unilateral acute purulent parotitis due to mandibular osteomyelitis. Clinical findings suggested a malignant tumor of the parotid gland, but cytology showed inflammatory changes and no malignant findings, and the patient was diagnosed with purulent parotitis. However, there was no drainage from the parotid duct confirmed in typical purulent parotitis. Bacterial examination detected Porphyromonas gingivalis, and CT showed a radicular cyst and mandibular osteomyelitis in the ipsilateral mandible. Based on these results, the patient was diagnosed with acute purulent parotitis caused by mandibular osteomyelitis associated with a dental infection. Long-term antibiotic administration for 4 weeks improved osteomyelitis. Patients with inflammation of the head and neck region triggered by such dental infection or osteomyelitis often first see a dentist, and there are not many opportunities for an otolaryngologist to see them. However, osteomyelitis patients are treated for a long period of time, and osteotomy may be required if they resist treatment, so early diagnosis is important. We suggest that when treating patients with refractory parotitis, the involvement of osteomyelitis should be suspected as the cause. In addition, this paper examined how to distinguish between typical retrograde infection-induced parotitis and osteomyelitis-induced parotitis based on differences in physical findings, bacterial test results, and imaging findings.

View full abstract

A 70-year-old man was referred to our department because of a fever of over 39℃, a sore throat, and skin eruptions for several months. We initially suspected a serious infection due to acute pharyngitis and laryngitis because many aphthous ulcers were found in his oral cavity, pharynx, and larynx. The pharyngeal and laryngeal findings were almost completely improved by intravenous antibiotic treatment, and the skin eruptions tended to disappear, but a slight elevation of inflammatory marker, remittent fever, and macrocytic anemia continued. In addition, new skin eruptions appeared on his chest, back, and both upper limbs 21 days after admission. Therefore, we performed a skin and bone marrow biopsy to scrutinize the new skin eruptions and anemia. As a result of this biopsy, he was diagnosed as Sweet’s syndrome associated with myelodysplastic syndrome （MDS）.
In cases of acute pharyngitis and laryngitis with skin eruptions, if the symptoms persist even after antibiotic treatment, there may be Sweet’s syndrome or autoimmune disease in the background.

View full abstract

Parotid sialolithiasis is rare in Japan although about 20％ of cases of calculi are parotid sialolithiasis in Europe or the US. In this report, six cases of parotid sialolithiasis, who were treated between 2016 and 2019 in our department, are presented and therapeutic methods are discussed. In case 1, a calculus existed anterior to the masseter muscle and was removed by a transoral approach. Case 2 had a large calculus, which was removed by extracutaneous incision. Case 3 had severe inflammation with abscess. After anti-inflammatory therapy, sialendoscopy was performed, however, a small stone remained. In case 4, a calculus, which was located in the anterior portion of Stensen’s duct, was extracted by sialendoscope. In case 5, a calculus was excreted spontaneously although the abscess had to be curetted. In case 6, who had a small calculus in the parotid, the course was observed without operation because symptoms were mild. Parotid sialolithiasis sometimes complicates an abscess. Patients with parotitis should be treated with anti-inflammatory therapy; sialendoscopy is contraindicated during acute inflammation at first. Thereafter, calculi should be reconfirmed by CT or ultrasound scanning and the therapeutic approach should be decided. If calculi exist anterior to the middle of the masseter muscle in Stensen’s duct, they may be removed by sialendoscopy. On the other hand, large calculi or those posterior to the middle of the masseter muscle may require a combined approach.

View full abstract

Sleep apnea syndrome often becomes a clinical problem in children suffering from Prader-Willi syndrome. Continuous positive airway pressure therapy is one of the effective therapeutic strategies for pediatric sleep apnea syndrome complicated with Prader–Willi syndrome. However, there have been few reports on the efficacy of surgical treatment. Two cases of pediatric sleep apnea syndrome complicated with Prader-Willi syndrome treated with surgery （tonsillectomy and adenoidectomy） were evaluated on polysomnography. The apnea hypopnea index improved in both cases. On the other hand, the clinical efficacy of surgical treatment differed between the two cases. Evaluation of the upper airway tract and polysomnography are necessary for pediatric sleep apnea syndrome complicated with Prader-Willi syndrome. Since the clinical symptoms of Prader-Willi syndrome change with age, re-examination of the polysomnography and therapeutic strategy combined surgery, as well as continuous positive airway pressure therapy are necessary based on the clinical symptoms.

View full abstract

There are few reports on the treatment of head and neck cancer during pregnancy, and in particular, there is only one such report in Japan, in which free flap reconstruction was performed while pregnancy was continued. We report a case of tongue cancer treated by free flap reconstruction surgery during pregnancy, followed by postoperative radiotherapy as soon as possible after delivery of the baby by caesarean section.
A 37-year-old woman at 23 weeks and 5 days of pregnancy was referred to our department for the treatment of a tumor on the right edge of her tongue. As a result of various examinations, we diagnosed tongue cancer （squamous cell carcinoma, cT2N2bM0, Stage IVA）. In consultation with the obstetrics and radiology departments, we decided to perform surgery while the pregnancy was continued.
We performed right tongue hemiresection, right neck dissection, and tongue reconstruction with a forearm flap at 28 weeks and 4 days of gestation. Six days after delivering a baby by caesarean section at 31 weeks and 5 days of pregnancy, which was 28 days after surgery, we started postoperative radiotherapy. For a period of about 1 year and 6 months after the completion of treatment, neither recurrence or metastasis of tongue cancer nor abnormal development or growth of the infant has been observed.
By working closely with other clinical departments, multimodal treatment including free-flap reconstruction may be possible even in cases of advanced tongue cancer during pregnancy.

View full abstract

A 2-year-old girl had nasopharyngeal reflux, dysarthria, and dysphagia. Video nasopharyngoscopy showed nasopharyngeal insufficiency due to left soft palate paralysis. We diagnosed idiopathic unilateral soft palate paralysis due to neuropathy of the glossopharyngeal and vagus nerves because viral antibody and brain MRI showed no abnormalities. Steroid was gradually administered over 9 days. After sixty days the paralysis completely disappeared. Idiopathic unilateral soft palate paralysis in an infant is a rare disease and has been reported in Japan only in cases 6 years or older. This may be because medical examination is difficult in infants and may not provide a reliable diagnosis. We considered that our approach is advantageous for diagnosis because an otolaryngologist can observe directly the soft palate from the nasal cavity using video nasopharyngoscopy.

View full abstract

We report a rare case of a foreign body in the left palatine tonsil. A 25-year-old female presented with a sore throat and pain on swallowing after eating deep fried shrimps. She underwent a medical examination at a clinic the next day and removal of a foreign body was attempted but failed. Since the sore throat persisted, she visited another clinic. However, the presence of a foreign body could not be confirmed, so she was referred to our hospital. We could not find any foreign body by inspection and endoscopic examination but could feel a hard object under the left palatine tonsil mucosa. Computed tomography revealed that a foreign body existed in the left palatine tonsil. We performed tonsillectomy and were able to find a small process resembling a saw, called a rostrum, in the left palatine tonsil. Because the rostrum had many spikes like barbs, removal of the foreign body was difficult.

View full abstract