The starting point for becoming a top surgeon is to have “good places” in the operating theatre. “Good place” in the operating theatre can have two meanings: a good operating field and a good environment in the operating theatre. In order to make a good operating field, this three steps (to make appropriate space, to keep and fix the operating field, to prepare appropriate tension of the tissue) are needed in all kinds of operations in the field of head and neck surgery. On the other hand, non-technical skills are necessary to make a good environment in the operating theatre. Non-technical skills consist of situation awareness, decision making, communication/teamwork, leadership. It is the most important and difficult for surgeons to make relaxing atmosphere that every member can speak up anytime in operating theatre. By explicitly describing how to make a “good place,” that so far had been conducted in a tacit manner in the operating theatre, surgery is expected to improve.

Actinomycosis is a rare, chronic and slowly progressive granulomatous disease, caused by Gram-positive, anaerobic bacteria of the Actinomyces species. The most common site of Actinomyces infection is the cervicofacial region, and actinomycosis of the middle ear and mastoid is very rare. Herein, we report a case of actinomycosis of the middle ear and mastoid, diagnosed from the histopathological features of specimens collected from the middle ear through exploratory tympanotomy.

A 46-year-old man presented to our hospital complaining of otorrhea and hearing loss on the left side, which failed to improve with antibiotic treatment for 9 months. Otoscopic examination revealed reddishness and thickening of the tympanic membrane. Pure tone audiometry showed moderate mixed hearing loss in the left ear. Histopathological examination of the middle ear specimen collected through myringotomy revealed inflammatory granulation tissue, consistent with the findings of computed tomography and magnetic resonance imaging of the temporal bone. Bacterial culture of the otorrhea fluid did not reveal any pathogens. He was treated with antibiotics for three weeks, but his condition failed to improve. Finally, we decided to perform exploratory tympanotomy, and found yellow granules surrounded by granulation tissue in the tympanic cavity. Histopathological examination of the granules revealed Gram-positive bacterial colonies, consistent with the diagnosis of actinomycosis. The patient was treated with penicillin for 1 year, with improvement. There has been no sign of recurrence since.

Difficulty in diagnosing actinomycosis by bacterial culture of the specimen is attributable to the fact that Actinomyces species are hard to grow on agar plates. In almost all the reported cases, the diagnosis of actinomycosis was made by histopathological examination of appropriate specimens. In case where otitis media fails to improve with antibiotic administration, clinicians should suspect actinomycosis and collect middle ear specimens for the diagnosis.

Herein, we present the clinical courses of 8 patients with acute visual disorder caused by paranasal sinus diseases. The patients included 2 cases of sinus mucocele, 2 cases of fungal sinusitis, and 4 cases of chronic sinusitis. All the patients underwent endoscopic sinus surgery. The median interval between the onset of visual disorder and surgery was 5.5 days (range, 1 to 9 days), and the visual disorder improved in 7 of the 8 cases. On preoperative CT, the sinuses adjacent to the optic nerve were filled with a soft tissue density. Bony wall defects between the sinus and optic nerve were recognized in 6 cases. These pathological changes were thought to be one of the main causes for the visual disorder. Orbital and periorbital abscesses were seen in two cases. Antibiotics were administered to all patients postoperatively. Intravenous corticosteroids were administered in the 6 patients without fungal sinusitis. The antifungal drug, voriconazole, was administered to 3 patients, including 2 patients with fungal sinusitis and 1 patient with chronic sinusitis associated with dysfunction of cranial nerves III, V2 and VI, which was considered to be attributable to invasive fungal sinusitis. Emergent endoscopic sinus surgery is necessary to achieve a good prognosis in patients with acute visual disorder caused by sinus diseases.

Herein, we report a case of pharyngeal/cervical trauma sustained due to an epileptic attack that developed while the patient was brushing her teeth. The patient was a 20-year-old woman with schizophrenia and epileptic psychosis, who was hospitalized at a local psychiatric hospital. She lost consciousness while brushing her teeth and fell down. A toothbrush was observed in the pharyngeal cavity and the patient was transported to our hospital for emergency treatment. The toothbrush was visualized by endoscopy; the brush side of the toothbrush was embedded in the right piriform sinus and the handle side had migrated into the pharynx. CT revealed subcutaneous and mediastinal emphysema and the brush located beside the right brachiocephalic artery. An emergency operation was performed on the same day; a tracheotomy was initially performed under intravenous anesthesia, followed by removal of the pharyngeal/cervical foreign body through a cervical incision under general anesthesia. The toothbrush had penetrated the right piriform sinus and reached the right brachiocephalic artery along the right common carotid artery. The tracheal fistula was closed on the 11th day after surgery, with oral intake by the patient resumed on the 25th day, and the patient transferred to the hospital psychiatric ward on the 41st postoperative day. It might be difficult to provide medical care smoothly for adults with severe mental illness.

Radiation therapy is one of multidisciplinary approaches used for the treatment of head and neck cancers, but it can lead to undesirable complications because of the close proximity of radiosensitive structures to the head and neck. These complications include pseudoaneurysm of the carotid artery. Although rupture of a carotid artery pseudoaneurysm is a rare complication, it is a life-threatening event with a high rate of mortality and morbidity, that requires emergency treatment. Endovascular packing of the pseudoaneurysm using coils, glue, or covered stents is associated with a higher success rate, in terms of immediate hemostasis, than surgical ligation of the common carotid artery or extracranial-to-intracranial bypass.

Herein, we report a patient with pharyngeal cancer who developed a carotid artery pseudoaneurysm after radiation therapy plus total pharyngolaryngoesophagectomy. The pseudoaneurysm was first recognized 16 years after the initial therapy, and endovascular packing was performed using coils and a bare stent. Three years later, the patient presented with rupture of the common carotid artery pseudoaneurysm into the free jejunum. Hemostasis was accomplished by emergency endovascular treatment, however, the patient died within a short time thereafter, of cerebral infarction.

It is necessary to promote awareness about this complication as well as to establish management strategies for carotid blowout syndrome post radiotherapy, as the likelihood of occurrence of this complication is likely to rise with the improved prognosis of head and neck cancer patients.

Nonresectable recurrent head and neck carcinoma is difficult to treat. Because most patients with recurrent head and neck cancer have exhausted the potential of surgery, radiotherapy and chemotherapy, nivolumab, an anti PD-1 antibody, began to be used after it became available in March 2017. We describe the case of a patient who died after a single administration of nivolumab. A 67-year-old man with squamous cell carcinoma of the head, neck and paranasopharynx underwent repeated chemotherapy and radiotherapy cycles for pulmonary metastases, however, he presented with multiple lung metastases again nine years after the initial treatment. Nivolumab was administered based on the expectation of long-term survival, but the patient developed generalized malaise and respiratory distress five days after administration of the drug. Chest computed tomography revealed evidence of pneumonia, but antibiotic administration proved ineffective and the patient died of respiratory failure 13 days after nivolumab administration. The cause of death was thought to be pneumonia caused by the infiltration of lymphocytes activated by the immune checkpoint inhibitor around the site of the lung metastasis and the irradiated area. Patients with head and neck cancer along with lung metastasis might be at an elevated risk for the development of pneumonitis. The decision to treat such patients with nivolumab should be made only after careful evaluation.

Although oral, pharyngeal, and cervical esophageal foreign bodies are frequently seen in daily practice, few systematic analyses conducted in large case populations have been reported. Herein, we present a review of the date of 752 patients (317 males/435 females) who visited our department with a suspected foreign body in the throat during the 10-year period from March 2007 to February 2017. We collected data on the type of foreign body, site of lodgment of the foreign body in the throat, and the type of treatment undertaken to remove the foreign body. The most common suspected foreign body was a fish bone, which accounted for 598 cases (79.5%), however, only 383 of these cases actually had a foreign body, of which in 322, the foreign body was a fish bone. In regard to the treatment, 694 (92.3%) of the 752 cases were treated on an outpatient basis. These 694 cases included 337 (44.8%) in which a foreign body was found and 357 (47.5%) in which no foreign body was found. Esophagogastroduodenoscopy was performed in 41 cases (5.5%) and 16 patients (2.1%) required treatment under general anesthesia.

Calcific tendinitis of the longus colli muscle is a little known disease to otolaryngologists, and is often misdiagnosed as a retropharyngeal abscess. We report three cases of calcific tendinitis of the longus the colli muscle. The patients presented with severe pharyngeal and neck pain and odynophagia of sudden onset, and were suspected to have an infectious disease at first, namely, retropharyngeal abscess or tetanus. They were eventually diagnosed as having calcific tendinitis of the longus colli muscle and treated with NSAIDs. According to the articles, observation of calcific deposition in the retropharyngeal space on CT images confirmed the diagnosis. In addition, we believe that careful local examination is important as an opportunity to distinguish between calcific tendinitis of the longus colli muscle and infectious disease.

We encountered a case of tracheobronchial chondritis that developed after surgical treatment for tongue cancer and neck abscess.

The patient was a 55-year-old man with tongue cancer (T3N0M0, stage III), who was treated by right hemiglossectomy, tissue flap reconstruction, right neck dissection and tracheostomy. Due to postoperative dysphagia, laryngeal elevation surgery was performed. Then, 82 days after the operation for tongue cancer, the patient developed a right neck abscess. The abscess resolved with incision and drainage and antibiotic administration, however, intermittent fever persisted. A neck and chest computed tomography showed tracheobronchial wall thickening. We concluded that the patient probably had autoimmune tracheobronchial chondritis. The chondritis improved with prednisolone administration.

A few similar cases have been reported in the literature. Therefore, we assume that tracheotomy and neck abscess could predispose to the development of autoimmune tracheobronchial chondritis. However, presence of other possiple autoimmune disorder in the patients must be excluded.

Acute epiglottitis refers to acute inflammation of the epiglottis, and rarely causes airway obstruction. A retrospective study was conducted of the data of 115 patients with acute epiglottitis seen from April 2007 to December 2017 (65 males and 50 females; age 12 to 85 years old; median age 45 years). The median duration from symptom onset to the first clinic visit was 3 days (range, 1 to 14 days). Eight (7%) of the 115 patients had diabetes, and 16 (13.9%) had an epiglottic cyst. We divided the patients into 6 groups by the laryngeal findings according to the classification of Katori et al. Forty-one (35.7%) of the 115 patients was classified into class IA, and 8 (7%) into class IIIB. The median duration of hospitalization was 5 days (2 to 26 days). Blood test performed on day 1 of hospitalization revealed a white blood cell (WBC) count in the range of 3400 to 25350/μl (median 10350/μl) and a serum C-reactive protein (CRP) level in the range of 0.01 to 23.3 mg/dl (median 2.5 mg/dl). The WBC count and serum CRP level on day 4 of hospitalization were significantly lower than those on day 1. Eight (7%) patients required the airway management such as tracheotomy or cricothyroidotomy. The patient age, laryngoscopic findings (severe epiglottic swelling and arytenoid edema; Katori’s classification class IIIB), and high inflammatory reaction (WBC ≥20000/μl and serum CRP ≥20 mg/dl) were significantly correlated with the need for airway management.