Masayoshi Kobayashi

Objective: To evaluate the therapeutic efficacy of combined olfactory training and pharmacotherapy for post-traumatic olfactory dysfunction. Methods: Fifty-one patients with post-traumatic olfactory dysfunction treated at Mie University Hospital (2003–2022) were retrospectively analysed. Patients received either medication only ( n = 33) or medication plus olfactory training ( n = 18). Olfactory function was assessed using T&T olfactometry. Pharmacotherapy consisted of tokishakuyakusan (7.5 g/day), zinc (150 mg/day) and methylcobalamin (1500 µg/day). Results: The cure rate was significantly higher in the combination group (50 percent) than in the medication-only group (21 percent) ( p = 0.037). The mean time to improvement was shorter with combination therapy (6 ± 3 vs 14 ± 7 months, p = 0.031). Among patients aged less than or equal to 35 years, the cure rate reached 100 percent. Conclusion: Olfactory training enhances the therapeutic effect of pharmacotherapy in post-traumatic olfactory dysfunction, especially in younger patients. This simple and safe combination therapy may serve as a practical treatment option for post-traumatic olfactory dysfunction.

Background: Endoscopic endonasal approach (EEA) has gained widespread acceptance as a surgical approach for treating sinonasal malignancies in the last decade. Objectives: This study examined the validity of the EEA as a standard modality for the surgical treatment of sinonasal malignancies. Design: A retrospective multicenter cohort study Methods: This study included patients with nasoethmoidal malignancies who underwent initial surgical treatment between 2014 and 2016 at 10 tertiary referral hospitals in Japan. The EEA, craniofacial approach (CA), and EEA combined with CA (EEAwCA) were used as the surgical methods. Results: The total number of participants was 110, with a median posttreatment observation period of 69 months. The olfactory cleft (26%) was the most frequent lesion site. Squamous cell carcinoma (29%) and olfactory neuroblastoma (24%) were the most frequently observed pathological classifications. EEA was performed in early-stage cases, and EEAwCA, which is frequently used for tumors that extend into the orbit and/or intracranial regions, was performed in advanced-stage cases. Negative-margin resection was achieved in 85%, 78%, and 64% of EEA, EEAwCA, and CA cases, respectively; postoperative radiotherapy was performed in 50%, 56%, and 36% of patients with EEA, EEAwCA, and CA, respectively; and the 5-year local control rates were 90%, 78%, and 82% for EEA, EEAwCA, and CA, respectively. En bloc resection for EEA, and postoperative irradiation for EEA and EEAwCA were associated with fewer local recurrences. Validation of the operation time, hospitalization period, intraoperative blood loss, and postoperative complications demonstrated the low invasiveness of the EEA. Conclusion: The EEA is a minimally invasive surgical modality with preferable oncological outcomes for the treatment of nasoethmoidal malignancies when adequately planned. Plain Language Summary: A look back at nose cancer surgery using a less invasive method through the nose Purpose: This study looked at a newer, less invasive surgery called the endoscopic endonasal approach (EEA), which goes through the nose to remove tumors in the nose and nearby areas. The goal was to see if this method could be used as a standard treatment. How the Study Was Done: Researchers looked back at 110 patients in Japan who had surgery for cancer in the nose and surrounding areas between 2014 and 2016. They had surgery using one of three methods: EEA (through the nose) CA (a more traditional open surgery) EEA combined with CA (used for more serious cases) What They Found: 1) Most patients had tumors in a part of the nose related to the sense of smell. 2) The most common types of cancer were squamous cell carcinoma and a rare nerve-related tumor. 3) The EEA was mostly used for early-stage cancers, and the combined method was used for more advanced cases. 4) The cancer was completely removed in about 85% of EEA cases, 78% of combined cases, and 64% of traditional cases. 5) People who had EEA had fewer side effects, lost less blood, and stayed in the hospital for a shorter time. 6) After 5 years, the cancer had not come back in 90% of EEA cases, 78% of combined cases, and 82% of traditional cases. 7) Patients who had radiation after surgery or had tumors removed in one piece had better results. Conclusion: The EEA is a safe and effective option for treating certain nose cancers, especially when it's carefully planned. It causes less harm to the body and works well for early-stage cancers.

Background/Objectives: Seromucinous hamartoma (SH) is an extremely rare benign glandular lesion arising in the nasal cavity and paranasal sinuses, characterized by proliferation of serous and mucinous glands. Preoperative diagnosis by biopsy is extremely uncommon, making it a diagnostic challenge. We report a case of SH and discuss its diagnostic difficulties and management. Case Presentation: A 52-year-old man presented with right-sided nasal obstruction. A lobulated mass in the posterior right nasal cavity was incidentally detected during transnasal endoscopy. The lesion persisted for one year without reduction. CT, MRI, and biopsy failed to provide a definitive diagnosis. The patient was referred to our department, and endoscopic surgery under general anesthesia was performed. The tumor was removed en bloc. Histopathological examination revealed glandular proliferation of mixed serous and mucinous glands within the subepithelial stroma, consistent with SH. Discussion: Preoperative diagnosis is difficult due to insufficient biopsy depth and limited recognition of this rare entity. Since the surface epithelium shows no atypia, identification of subepithelial glandular proliferation is essential. Larger and deeper biopsy specimens and communication with pathologists may improve diagnostic yield. Surgical excision is the treatment of choice. As SH often arises in the posterior nasal cavity and is highly vascular, en bloc resection under general anesthesia is recommended. Conclusions: Recognition of SH is important to improve diagnostic accuracy. Appropriate biopsy strategy and surgical planning based on tumor location are essential.

SMARCA4-deficient sinonasal carcinoma is a recently proposed tumor entity that is rare and associated with a poor prognosis. No standardized treatment strategy has been established. We report a case of SMARCA4-deficient sinonasal carcinoma treated at our department. A 47-year-old woman was referred for treatment of a tumor of the left nasal cavity. The biopsy at a previous institution suggested a neuroendocrine tumor, but it was finally diagnosed as olfactory neuroblastoma. Imaging revealed no lymph node or distant metastases. Endoscopic endonasal resection of the malignant sinonasal tumor was performed with resection and reconstruction of the anterior skull base, achieving complete removal of the tumor. Postoperative intensity modulated radiation therapy (IMRT, 60 Gy) was administered. During IMRT, the histopathological examination confirmed the diagnosis of SMARCA4-deficient carcinoma. Adjuvant chemotherapy following the protocol for undifferentiated carcinoma was administered using the FP regimen (5-fluorouracil 800 mg/m ² and cisplatin 80 mg/m ² ) for 3 cycles. At 2 years and 1 month after surgery, the patient remains alive with no evidence of disease. SMARCA4-deficient carcinoma is an aggressive and poorly differentiated tumor with a poor prognosis, and our experience suggests that a multimodal approach combining surgery, radiation therapy, and chemotherapy following the treatment strategy for undifferentiated carcinoma is effective.

Biphenotypic sinonasal sarcoma (BSNS) is a very rare, locally aggressive sarcoma arising in the sinonasal region, initially recognized as low-grade sinonasal sarcoma with neural and myogenic differentiation. Here, we report a case of BSNS extending into the intracranial and intraorbital regions, finally diagnosed by a break-apart fluorescence in situ hybridization (FISH) assay for rearrangements of PAX3. A 50-year-old woman presented with left diplopia and exophthalmos. CT and MRI revealed a large ethmoidal mass with intracranial and intraorbital extension. Since preoperative biopsy suggested a benign tumor, endoscopic endonasal resection was performed while preserving the anterior skull base and intraorbital structures. Postoperative histopathological diagnosis indicated synovial sarcoma, and proton beam therapy with adjuvant chemotherapy was subsequently administered. After treatment, FISH demonstrated rearrangements of PAX3 and MAML3 genes, leading to a revised diagnosis of BSNS, which typically does not require chemotherapy due to its non-metastatic behavior. Eleven years after treatment, the patient remains free of recurrence. Understanding BSNS is essential to avoid excessive intervention, and confirmation of PAX3 rearrangement by FISH or equivalent molecular testing is crucial for accurate diagnosis.

Introduction and importance: Although bilateral congenital choanal atresia (CCA) requires early intervention to open closure walls for safe breathing, it is desirable to be withheld until an infant acquires surgical and anesthetic tolerance. Here we introduce an infant of CCA whose closure wall had thickened during a waiting period for an elective surgery. Case presentation: The choana of the patient could not be identified by intranasal fiberscopy and the bilateral CCA was found by CT scan on day 17 after birth. Since he could breathe orally without distress, surgery was withheld until he acquires the tolerance. At nine weeks old, however, CT image detected thickening of the closure wall. At 10 weeks old, he underwent scheduled surgery in which the bilateral closure walls were removed together with attached posterior part of the nasal septum under endoscopic endonasal approach. The patient became able to breath nasally and the choana remained open without restenosis at 3 years after surgery. Clinical discussion: This is the first CCA case reporting closure walls thickened during a waiting period for an elective surgery. Although waiting for surgery was systemically safer by growth, the surgery became more invasive to prevention from restenosis. Conclusions: This case suggests that we must decide appropriate timing of surgery in an infant, considering dilemma between systemic safety ensuring and lesion aggravation by waiting for surgery. Highlights:

Intensity-modulated radiation therapy (IMRT) has been increasingly used as a new radiation modality for unresectable non-small cell lung cancer (NSCLC). The risk factors for radiation pneumonitis (RP) during consolidation durvalumab following concurrent chemoradiotherapy (CCRT) using IMRT have not been thoroughly investigated. This retrospective study analyzed medical record data from consecutive patients diagnosed with NSCLC who underwent CCRT and consolidation durvalumab at our institution between April 2018 and September 2022. Since we adopted IMRT for the treatment of NSCLC in April 2020, these patients were categorized into two groups: those treated with IMRT after April 2020 and those treated with three-dimensional conformal radiotherapy (3D-CRT) before April 2020. A total of 31 patients underwent IMRT (the IMRT group), while 25 patients underwent 3D-CRT (the 3D-CRT group). In both groups, the total dose was 60 Gy in 30 fractions. The cumulative incidence of ≥ grade 2 RP at 12 months was significantly lower in the IMRT group than in the 3D-CRT group (27.0% vs. 64.0%, hazard ratio [HR]: 0.338, 95% confidence interval [CI]: 0.144–0.793, p = 0.013). In the multivariable analysis, V20 (≥ 25.6%, HR: 2.706, 95% CI: 1.168–6.269, p = 0.020) and radiotherapy technique (IMRT, HR: 0.414, 95% CI: 0.172–0.994, p = 0.048) were identified as significant risk factors for ≥ grade 2 RP. IMRT is associated with a lower rate of ≥ grade 2 RP in patients with NSCLC who received CCRT followed by durvalumab.