'Precursory symptoms, awareness or progression of facial palsy' are more useful than 'forehead wrinkling ability' in differentiating central facial palsy examined in the emergency department.

BACKGROUND: Forehead wrinkling ability has been considered to be the sign of the central facial palsy (CFP). AIMS/OBJECTIVES: To identify characteristics of peripheral FP (PFP) patients in the emergency room (ER), differentiate PFP from central FP (CFP), and assess the utility of forehead wrinkling for this purpose. MATERIALS AND METHODS: ER patients with FP were clinically split into PFP (72 patients) and CFP (161 patients) groups. Factors like age, sex, medical history, time from onset to consultation, symptom awareness or progression, precursory symptoms, forehead wrinkling, and imaging history were compared. Multivariate analysis differentiated PFP from CFP, examining misdiagnosis risks based on forehead wrinkling. RESULTS: Precursory symptoms and symptom awareness or progression had the highest odds ratios. Some PFP patients could wrinkle their foreheads, typically examined within 1 day of symptoms. PFP patients had more same-day imaging than those assessed a day later. CONCLUSIONS AND SIGNIFICANCE: Forehead wrinkling, a traditional CFP sign, is also common in early-stage PFP, decreasing its diagnostic reliability. Patients with solely CFP unable to wrinkle the forehead are very rare at a single institution. Evaluating precursors symptoms, and FP awareness and progression is crucial for differentiation.

Bilateral Nontuberculous Mycobacterial Otitis Media: A Case Report.

Established treatment strategies for nontuberculous mycobacterial (NTM) infections are currently lacking, and whether surgical treatment should be applied in combination with antibiotic therapy remains debatable. Here, we report a case of bilateral otitis media caused by Mycobacterium abscessusa, a highly antibiotic-resistant bacterium. Many reported cases of NTM otitis media are unilateral, in which hearing of the contralateral ear is preserved. In the present case, strategies to improve hearing outcomes were considered, as both ears were affected. A 27-year-old woman presented with bilateral otorrhea that had lasted for the past 9 months. Bacterial culture showed M. abscessus in both ears. Based on drug sensitivity tests, clarithromycin, amikacin, and imipenem were administered. Three days after treatment initiation, diseased tissues were removed from the right middle ear, which had impaired hearing. On day 38, otorrhea stopped in both ears, and the hearing improved. Computed tomography revealed air in both middle ears. No apparent recurrence was detected. Under the same antibiotic therapy, resolution of diseased tissues and improvement in hearing were similar between the ears with and without surgery, suggesting that surgery is not always necessary. This finding may be incorporated into the treatment guidelines for NTM infections in the future.

Indications of Effective Hyperbaric Oxygen Therapy Combined With Steroid Therapy for Sudden Hearing Loss.

OBJECTIVE: This study evaluated the therapeutic effect of hyperbaric oxygen therapy (HBOT) combined with steroid therapy to treat sudden hearing loss and examined the index associated with excellent therapeutic effect. METHODS: We included 109 patients with sudden hearing loss. Patients were divided into the HBOT combination group (59 sides) treated with HBOT and steroid therapy and HBOT noncombination group (50 sides) involving steroid therapy only. The recovery rate of each group was compared according to the severity of hearing loss. Blood samples were evaluated and inflammatory markers, such as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), were calculated and compared by severity. We evaluated the usefulness of inflammatory markers for predicting recovery rate, and calculated cutoff values were also evaluated. RESULTS: The HBOT combination group exhibited a higher overall recovery rate than the HBOT noncombination group, particularly in severe cases. However, there was no significant difference in the severity of hearing loss based on various inflammatory markers. NLR and PLR are useful for predicting the effect in patients treated with concomitant HBOT. By setting 2.43 and 146.67 as cutoff values for NLR and PLR, respectively, we observed that lower values resulted in better recovery rates. CONCLUSION: The use of HBOT is effective for severe cases and early blood flow disorders with low NLR and PLR and less inflammation. When determining treatment, not only should the severity of hearing loss be considered, but also the NLR and PLR should be evaluated and examined based on the cutoff values.

Preoperative prediction of sinonasal papilloma by artificial intelligence using nasal video endoscopy: a retrospective study.

Sinonasal inverted papilloma (IP) is at risk of recurrence and malignancy, and early diagnosis using nasal endoscopy is essential. We thus developed a diagnostic system using artificial intelligence (AI) to identify nasal sinus papilloma. Endoscopic surgery videos of 53 patients undergoing endoscopic sinus surgery were edited to train and evaluate deep neural network models and then a diagnostic system was developed. The correct diagnosis rate based on visual examination by otolaryngologists was also evaluated using the same videos and compared with that of the AI diagnostic system patients. Main outcomes evaluated included the percentage of correct diagnoses compared to AI diagnosis and the correct diagnosis rate for otolaryngologists based on years of practice experience. The diagnostic system had an area under the curve of 0.874, accuracy of 0.843, false positive rate of 0.124, and false negative rate of 0.191. The average correct diagnosis rate among otolaryngologists was 69.4%, indicating that the AI was highly accurate. Evidently, although the number of cases was small, a highly accurate diagnostic system was created. Future studies with larger samples to improve the accuracy of the system and expand the range of diseases that can be detected for more clinical applications are warranted.

Morphological relationships between external auditory canal and vital structures of tympanic cavity.

PURPOSE: We aimed to evaluate the morphology of the external auditory canal (EAC) using a three-dimensional (3D) reconstruction of computed tomography (CT) scans of the temporal bone to corroborate and predict important anatomical structures involved in middle ear surgery based on the EAC morphology. METHODS: Temporal bone CT from 62 patients (120 ears) was used to perform 3D reconstruction (maximum intensity projection), of which 32 patients (60 ears) had chronic otitis media and 30 patients (60 ears) had normal temporal bones. The anatomical morphology of the EAC, tympanic sinus, vertical portion of the facial nerve, and jugular bulb were measured, and the anatomical relationship between the EAC morphology and important structures of the middle ear was analyzed. RESULTS: In ears with chronic otitis media, the overhang of the inferior wall of the EAC was significantly more than that in normal ears, and the antero-posterior length of the bony tympanic ring was short. Furthermore, the tympanic sinus was shallow, and vertical portion of the facial nerve tended to run outward. The EAC morphology correlated with the tympanic sinus depth and outward orientation of the vertical portion of the facial nerve. CONCLUSION: A severe overhang of the inferior wall of the EAC and short antero-posterior length of the bony tympanic ring indicates a higher possibility of a shallow tympanic sinus and an outward orientation of the vertical portion of the facial nerve. These findings aid in predicting the difficulty of tympanic sinus operation and reducing facial nerve damage risk during EAC excision.

High CD4 + T-Cell/B-Cell Ratio in the Paranasal Sinus Mucosa of Patients with Eosinophilic Chronic Rhinosinusitis.

Introduction Chronic rhinosinusitis (CRS) is commonly classified based on the presence or absence of nasal polyps (NPs). Eosinophil infiltration is observed in NPs of patients in Western countries. In contrast, in East Asian countries, including Japan, CRS with NPs (CRSwNP) is subdivided based on the presence (eosinophilic CRS [ECRS]) or absence (non-eosinophilic CRS [NECRS]) of eosinophils in NPs. However, detailed analyses of other immune cells, such as lymphocytes, in NPs have not been performed. Therefore, clarification of the types of cells that infiltrate NPs is important to understand CRS pathogenesis. Objectives We analyzed the lymphocytes that infiltrate the paranasal sinus mucosa of ECRS and NECRS patients. Methods Eighteen patients with CRSwNP participated in this study, out of whom 6 were NECRS patients, and 12 were ECRS patients. The mucosa specimens, collected from patients during sinus surgeries, were subjected to collagenase treatment to prepare single cell suspensions. Then, mononuclear cells were isolated, and CD4 + T, CD8 + T, and CD20 + B-cell populations were examined using flow cytometry. Results In both NECRS and ECRS patients, CD8 + T-cells were dominant over CD4 + T-cells. Notably, CD4 + T-cell/B-cell ratio, but not CD8 + T-cell/B-cell or CD4 + T-cell/CD8 + T-cell ratios, was significantly higher in ECRS patients than in NECRS patients. Conclusion The CD4 + T-cell/B-cell ratio can be used as a potential indicator to differentiate between ECRS and NECRS.

Anatomical Features Around Eustachian Tube in Eosinophilic Otitis Media With Eosinophilic Sinusitis.

OBJECTIVES/HYPOTHESIS: This study investigated the relationships between anatomical findings around the eustachian tube (ET) and eosinophilic otitis media (EOM) accompanied by eosinophilic chronic rhinosinusitis (ECRS). STUDY DESIGN: This study employed axial, coronal, sagittal and oblique computed tomography. METHODS: Patients who underwent endoscopic sinus surgery at the Department of Otolaryngology, Toho University Medical Center Omori Hospital and were diagnosed with ECRS (106 patients) based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis study were included. Subsequently, the presence of EOM accompanied by ECRS in 212 ear sides was assessed, and preoperative sinus computed tomography was used to evaluate various anatomical findings, such as the development of the sphenoid sinus and mastoid cells at the apex of petrous bone, the angle and length of the ET, and the size of the tympanic orifice of the ET. The relationships between these anatomical findings and the presence of EOM were analyzed statistically. RESULTS: EOM accompanied by ECRS was associated with a high peripheral blood eosinophil count and bronchial asthma. Among anatomical factors, the absence of peri-ET cells or petrous apex cells, and a low angle and short length of the ET, were risk factors for the onset of EOM. CONCLUSION: Anatomical factors such as the absence of peri-eustachian cells or petrous apex cells, and low angle or short length of the ET, are risk factors for the onset of EOM along with ECRS. Assessment of these factors may help in preventing the future onset or aggravation of EOM. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2689-E2695, 2021.

Anatomical Factors that Can Predict the Structure of Lamina Papyracea for Endoscopic Sinus Surgery.

OBJECTIVES: This study investigated morphological variations of lamina papyracea, the structure that should be carefully considered when opening posterior ethmoid sinus during endoscopic sinus surgery, to avoid injury. STUDY DESIGN: This study employed axial, coronal, and sagittal computed tomography. METHODS: Using computed tomography images of 228 face-sides, various anatomical parameters were determined: distances of the anterior and posterior ethmoid arteries from the skull base, and from the third lamella; changes in the angles of the lamina papyracea at the anterior and posterior ethmoid sinuses; and presence or absence of supraorbital ethmoid cell (SECs), Onodi cell, and Haller cell. The relationship between the distances which indicate the point of maximum projection by the lamina papyracea among third lamina and posterior ethmoid artery into the posterior ethmoid sinus and these anatomical factors were analyzed statistically. RESULTS: The projection distance of lamina papyracea into the posterior ethmoid sinus was -2.6 mm to 3.4 mm, and in 41.2% of cases, projection in the direction of the nasal cavity was greater than that of the lamina papyracea at the anterior ethmoid sinus. This distance increased with increasing distance of the maximum projection point from the skull base and increasing floating distances of the anterior and posterior ethmoid arteries. The number of subjects with large projection distances was increased among those with floating posterior ethmoid arteries. In addition, subjects with SECs had significantly greater projection distances. CONCLUSIONS: Particular care should be taken to avoid injury to the lamina papyracea when opening the posterior ethmoid sinus in subjects with floating anterior or posterior ethmoid arteries, and/or SEC. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E19-E25, 2021.

Anatomical variation of the pneumatized superior turbinate and its impact on endoscopic sinus surgery in chronic rhinosinusitis.

PURPOSE: The posterior ethmoid sinus is adjacent to important structures, such as the orbit, optic nerve, skull base, and ostium of the sphenoid sinus. The purpose of this study was to examine the effect of pneumatization of the superior turbinate (ST) and its basal lamella, and of the position of the anterior wall of the sphenoid sinus, on opening of the posterior ethmoid and sphenoid sinuses. METHODS: On axial, coronal, and sagittal computed tomography images, 394 sinuses of 197 patients who underwent endoscopic sinus surgery at Toho University Omori Medical Center in Tokyo, Japan, were classified according to the presence or absence of pneumatization of the ST and its basal lamella. The basal lamella of the ST was classified separately into the vertical and horizontal portions. We examined whether the classification of the anterior wall of the sphenoid sinus was associated with the structure of the ST. RESULTS: Pneumatization was observed in the ST in 28 sinuses (7.1%), in the vertical portion of the basal lamella in 127 (32.2%), and in the horizontal portion of the basal lamella in 90 (22.8%). Pneumatization in the horizontal portion of the basal lamella was significantly more common in the anterior sphenoidal wall classified as optic-canal type. CONCLUSION: Consideration should be given to the pneumatization of the ST and its basal lamella and optic-canal-type anterior sphenoidal wall, because these reduce the volume of the posterior-most ethmoid cell and may increase the risk of damaging the skull base and optic nerve.

IgG4-related disease with pseudotumor formation in the larynx.

Mikulicz's disease, an immunoglobulin G4-related disease (IgG4-RD) occurs frequently in the head and neck region but rarely in the larynx. We report a case of IgG4-RD with pseudotumor formation in the larynx. A 50-year-old man presented at our facility for a complete physical examination and diagnostic testing of a left arytenoid tumor. On examination, a large supraglottic mass was noted with signs of dyspnea. Movement disorder of the vocal fold was absent. The patient underwent surgery with general anesthesia to improve respiratory symptoms and a resected specimen was submitted for diagnosis. The pathology findings revealed lymph follicle formation, interstitial follicular fibrosis, angiogenesis, and inflammatory cell infiltration with plasmacytosis. Immunohistologic staining at high magnification revealed one hundred or more IgG4-positive plasma cells and fifty percent IgG4/IgG. In addition, obliterative phlebitis was observed. Medical history was positive for retroperitoneal fibrosis with serum IgG4 levels below the diagnostic criteria of IgG4-RD, but histological characteristics of IgG4-RD were met. The diagnosis of IgG4-RD was established, oral treatment with prednisolone (0.6 mg/kg/day) was initiated, and the tumor reduced in size. IgG4-RD may cause irreversible functional impairment. Early diagnosis and treatment are important in reducing the risk of permanent impairment of vocal fold mobility.

Resection of a Superior Mediastinal Mature Teratoma Using Intraoperative Neural Monitoring.

A 33-year-old woman presented with a right cervical mass. Contrast computed tomography showed a multilocular tumor with a clear border and heterogeneous contents including fat and calcification. The tumor was located adjacent to the vagus and recurrent nerves. To avoid injury of these nerves, we resected the tumor through a median sternotomy and right cervical lateral incision. Intraoperative neural monitoring was performed using an NIM TriVantage EMG tube (Medtronic, Minneapolis, MN). After the surgery, no neuropathy such as hoarseness was recognized. Pathological diagnosis showed a benign mature teratoma. Intraoperative neural monitoring is useful for superior mediastinal surgery around the vagus and recurrent nerves.