Extracapsular Dissection With Narrow-Band Imaging Using the Transnasal Endoscopic Tri-port Approach for Extracranial Trigeminal Schwannoma: A Case Report.

The pterygopalatine fossa and infratemporal fossa are often approached through an external incision because of their deep facial location, but this can present problems such as facial scarring and deformity. In schwannoma surgery, intraneural dissection is a useful surgical technique for achieving gross total resection while preserving the capsule, including the nerves. For appropriate enucleation and preservation of the functional nerve, it is indispensable to distinguish between the pseudocapsule and the tumor capsule. This case report presents a case of endonasal surgical intervention for an extracranial trigeminal schwannoma employing the tri-port approach and narrow-band imaging.

New insights into chronic rhinosinusitis associated with IgG4-related disease.

IgG4-related disease (IgG4-RD) is a chronic inflammatory disorder characterized by elevated IgG4 serum levels, abundant IgG4-positive plasmacyte infiltration, and fibrosis of various organs, including the head and neck. We aimed to provide an overall review of IgG4-RD in the sinonasal region and propose a novel entity and criteria of chronic rhinosinusitis (CRS) associated with IgG4-RD as "IgG4-CRS," a distinct manifestation of IgG4-RD in the sinonasal region. Sinonasal involvement has been increasingly recognized; however, this region is not included in the classic IgG4-RD-affected organs. The clinical features of IgG4-CRS, including its prevalence and relationship with allergies and olfactory disturbances, have also been explored. Serum IgG4 levels and IgG4-positive plasma cell infiltrations, crucial diagnostic factors, have been discussed in association with IgG4-CRS pathogenesis. Fibrosis, a hallmark of IgG4-RD, is observed in sinonasal tissues; however, typical fibrosis, such as storiform fibrosis, is not usually found. Mimics or complications in eosinophilic CRS (ECRS) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are highlighted. Treatment often involves typically effective glucocorticoids. Organ-specific diagnostic criteria for the sinonasal region have not currently been established. Hence, this review aims to foster awareness and understanding of IgG4-CRS among ENT physicians and to provide a basis for future research and diagnostic refinement.

Narrow band imaging accentuates differences in contrast between cartilage and perichondrium in the elevation of the muco-perichondrium flap during septoplasty and open septorhinoplasty.

OBJECTIVE: In the elevation of the muco-perichondrium flap during septoplasty and septorhinoplasty, it is important to elevate the subperichondrial layer. When performing subperichondrial elevation of the flap, the surgeon uses differences in color tone to distinguish the perichondrium from cartilage; however, it is relatively difficult to understand these differences and to share them with assistants. Furthermore, the perichondrium at the caudal end adheres tightly to the cartilage, making it difficult to detach accurately the subperichondrial layer. Narrow band imaging (NBI) is an optical technology that facilitates detailed observation of microvessels in the mucosal surface layer. In this study, we investigated whether NBI is better than white light (WL) in accentuating differences in contrast between cartilage and perichondrium in the elevation of the muco-perichondrium flap during septoplasty and septorhinoplasty. METHODS: Twenty-six sides of 15 patients (the modified Killian approach was used in two patients, the hemitransfixion approach was used in seven patients, and open septorhinoplasty was used in six patients) with elevated muco-perichondrium flaps were studied under WL endoscopy and NBI. The brightness of the perichondrium and cartilage and the differences between the two tissues were compared between WL and NBI using ImageJ 1.53a. Next, the WL and NBI endoscopic images used for cartilage identification were divided into the three separate primary color channels of red, green, and blue, and the brightness of the perichondrium and cartilage were measured separately for each channel. RESULTS: Under WL, the perichondrium appeared reddish-white and the cartilage appeared white, whereas under NBI the perichondrium appeared greenish-gray, differentiating it from the white cartilage. The difference in brightness between the cartilage and perichondrium was significantly higher on NBI (grayscale difference 80.8 (SD 42.4)) than on WL imaging (grayscale difference 35.6 (SD 31.1)) (p<0.001). In the red channel, the difference in image intensity between cartilage and perichondrium was significantly higher on NBI than on WL imaging (Red WL grayscale difference -1.5 (SD 33.7), Red NBI grayscale difference 90.0 (SD 56.7); p<0.001). CONCLUSIONS: NBI is better than WL at accentuating the difference in contrast between cartilage and the perichondrium during the elevation of the muco-perichondrium flap during septoplasty and septorhinoplasty. The difference in the processing of red light between WL and NBI provides the largest contribution to the differentiation of cartilage from the perichondrium under WL and NBI. We believe that NBI can be usefully applied during septoplasty and septorhinoplasty to distinguish cartilage from the perichondrium with precision.

Endoscopy-assisted transoral resection of a parapharyngeal space schwannoma without mandibular dissection.

Of the schwannomas that arise from the parapharyngeal space, those in the high cervical region are particularly invasive, requiring mandibular dissection. Because these tumors are benign, however, excessive surgical invasion and postoperative neurological complications should be avoided. Postoperative dropout symptoms may be avoided by intracapsular extraction, including nerve integrity monitoring (NIM) and narrow-band imaging (NBI). Video laryngoscopy surgery is reported to be useful for transoral resection of pharyngeal and laryngeal tumors. This report describes the transoral removal of a giant schwannoma located in the high cervical region from a 74-years-old man using a surgical support device without mandibular dissection. The tumor was located on the right lateral pharyngeal wall and extended from the upper oropharynx to the hypopharynx while compressing the epiglottis to the skull base. No separation was observed between the internal jugular vein and the internal carotid artery. The tumor was diagnosed as a schwannoma with no malignancy on the basis of the histology of a core needle biopsy (CNB), and was completely and safely removed endoscopically using NIM and NBI, with no need for an external incision or mandibular dissection. This case illustrates that even a huge sympathetic schwannoma located in the parapharyngeal space at a high cervical position can be excised transorally using video-laryngoscopic surgery (TOVS) without mandibular dissection.

Imprint cytology of biphenotypic sinonasal sarcoma of the paranasal sinus: A case report.

Biphenotypic sinonasal sarcoma (BSNS) is a rare low-grade spindle cell sarcoma that predominantly affects middle-aged women with multiple tumors in the sinonasal tract. BSNS shows biphenotypic expression of neural and myogenic markers on immunohistochemistry (IHC) with a specific chimeric PAX3-MAML3 fusion. The cytological features of BSNS have so far not been reported. Here, we describe a case of BSNS including findings of imprint cytology, histology, IHC, and genetic analysis. A 30-year-old woman presented with a nodular tumor that completely occupied the ethmoid sinus. The tumor was resected and submitted for imprint cytology, which revealed relatively bland spindle tumor cells that had mildly enlarged oval to spindle-shaped nuclei with fine nuclear chromatin and a thin nuclear rim in a clear background. Nucleoli were inconspicuous and there was no significant nuclear atypia and pleomorphism. These cytological findings were consistent with the histology of low-grade spindle cell sarcoma in BSNS. On IHC, the tumor cells were focally positive for S-100 protein and α-smooth muscle actin; nuclear ß-catenin expression was also seen. PAX3 split signals were detected in 52% of tumor cells by fluorescence in situ hybridization. Reverse transcriptase-polymerase chain reaction also identified a chimeric PAX3-MAML3 fusion gene. Based on these findings, we diagnosed the tumor as BSNS. Our findings revealed that a relatively bland spindle cell cytology with a clear background is a characteristic feature of BSNS. BSNS should therefore be differentiated from benign and bland-appearing malignant spindle cell tumors and the combination of cytology, histology, IHC, and genetic analysis facilitates the diagnosis of BSNS.

Accessory parotid gland tumors: A series of 4 cases.

Accessory parotid gland tumors are clinically rare, and their management remains unclear. In this article, we describe our experience with 4 patients-2 males and 2 females, aged 13 to 66 years-who were diagnosed with an accessory parotid gland tumor. All patients presented with an asymptomatic midcheek swelling, and all underwent fine-needle aspiration biopsy, ultrasonography, computed tomography, and magnetic resonance imaging. A standard parotidectomy was performed on all patients. Postoperatively, 2 patients were found to have a malignant tumor, while the other 2 had a pleomorphic adenoma. No patient experienced any obvious facial nerve injuries postoperatively, and no recurrences were observed. We discuss the preoperative evaluation, treatment, and prognosis of these tumors, and we briefly describe the literature. The first choice of treatment for accessory parotid gland tumors is surgical resection. In our experience, a standard parotidectomy approach is safe and cosmetically appealing.

Carcinoma ex pleomorphic adenoma of the parotid gland: a multi-institutional retrospective analysis in the Northern Japan Head and Neck Cancer Society.

CONCLUSION: The 3-year progression-free survival rate of non-invasive salivary duct carcinoma (SDC) or adenocarcinoma not otherwise specified (NOS) was significantly better than that of invasive SDC or adenocarcinoma NOS in Carcinoma ex pleomorphic adenoma (CXPA). The presence of invasion is an important prognostic factor for SDC and adenocarcinoma NOS in CXPA. OBJECTIVES: CXPA is a rare parotid gland malignant tumor for which therapy is not yet standardized. The purpose of this study was to review the characteristics of CXPA patients and to analyze their outcomes in the Northern Japan Head and Neck Cancer Society. METHOD: The medical records of 33 patients who had been provided initial treatment in 12 institutes of northern Japan from 2002-2011 were reviewed as a multi-institutional retrospective study. RESULTS: The 3-year overall and progression-free survival rate of all patients was 79.9% and 76.8%, respectively. Both the 3-year overall and progression-free survival rates were 87.5% for patients with non-invasive SDC or adenocarcinoma NOS. The 3-year overall and progression-free survival rates for patients with invasive SDC or adenocarcinoma NOS were 60.4% and 30.5%, respectively. The progression-free survival rates for patients with invasive SDC or adenocarcinoma NOS was significantly poor (p < 0.05).

Pneumolabyrinth with Labyrinthitis as the Suspected Cause.

Pneumolabyrinth is a rare condition with air bubbles existing in the vestibule and/or cochlea. We report a case of pneumolabyrinth without trauma that was suspected to be caused by labyrinthitis. A 65-year-old man presented with vertigo and hearing loss in the left ear after catching a cold. Computed tomography performed after there had been no improvement in the patient's symptoms showed the presence of air bubbles in the vestibule, semicircular canals and cochlea. The patient was transferred to our hospital with suspected perilymphatic fistula. Bacterial infection was suspected after the laboratory tests had indicated a severe inflammatory response, and the patient was treated with antibiotics. However, no bacteria were detected in a bacterial culture of the otorrhea. An exploratory tympanotomy was performed to improve the patient's staggering gait and to examine the middle ear, with no obvious fistula being observed. Subsequent fenestration of the round window revealed a white mass that appeared to contain bacteria which was collected from the cochlea and submitted for analysis and bacterial culture. However, no bacteria were detected and the mass contained white blood cells. We suspected pneumolabyrinth following labyrinth infection. However, the cause of air bubble formation remains unclear and needs to be validated with further research.

Radiological Assessment of the Anatomy of Frontal Recess Cells and the Anterior Ethmoidal Artery.

It is necessary for the surgeon to be familiar with frontal recess anatomy during an endoscopic approach to the frontal sinuses. The aim of this study was to evaluate the prevalence of frontal recess cells in Japanese adults as well as the association between the frontal recess and the location of the anterior ethmoidal artery (AEA). The frontal recess cells and the AEAs were retrospectively evaluated in CT scans of the nasal and paranasal sinuses for 89 patients. The prevalence of agger nasi cells was 90.7%. The frequency of frontal cell types 1, 2, 3 and 4 was 28.8, 0.6, 2.6 and 0%, respectively. Suprabullar cells (SBCs) and frontal bullar cells (FBCs) were identified in 78/96 sides (81.3%) and 24/96 sides (24%), respectively. The prevalence of the medial group of frontal recess cells (interfrontal sinus septal cells) was 12.4%. In 42/61 sides (68.9%), the AEAs were located within the posterior margin of the SBCs or the FBCs. Therefore, SBCs, FBCs and the vertical portion of the middle turbinate are reliable landmarks for the identification of AEAs.

A Case Study of Anisakiasis in the Palatine Tonsils.

Anisakidosis is a nematode infection caused by the ingestion of larvae-infected raw or undercooked fish. Although gastric anisakiasis is a common disease in Japan due to the popularity of eating raw and undercooked fish, reports of anisakiasis in the tonsils are extremely rare. A 68-year-old man presenting with clinical features of peritonsillitis was admitted for examination. The right peritonsillar region exhibited slight edematous swelling and rash, and a white foreign body was observed. This foreign body was removed, and pathological examination revealed Anisakis.

[Syphilis].

In Japan, the incidence of syphilis has decreased, and clinicians might be more likely to overlook syphilis than before. We show typical clinical manifestations and treatment of syphilis for clinicians unfamiliar with the disease and emphasize that two types of serologic test, non treponemal tests and specific treponemal tests, are essential for diagnosis of syphilis. Recent automated serologic tests for syphilis are useful to examine patients' progress after they are treated. The early stage of syphilis is gradually spreading among men in Japan, and HIV coinfections are often caused by homosexual contacts. We present a sample figure in the classic medical book, "Atlas of syphilis and the venereal diseases".

[Two cases of HIV-1 acute infection with antibody negative by immunochromatography method].

We found two cases of HIV-1 acute infection, confirmed by nucleic amplification test (NAT) and/or RT-PCR, with HIV-1 antibody negative by immunochromatography (IC) method but weakly positive by particle agglutination (PA) test. These cases suggested that IC method was less sensitive than PA test in the detection of acute infections. It is necessary to execute the post counseling that considers the possibility of the acute infection in public health centers and testing places where IC method is used for the screening test. It is also important to recommend taking the following re-examination after a certain period to a person who seems to have had a chance of infection in a short time before testing.