In patients with squamous cell carcinoma of the head and neck (SCCHN) who are in their terminal stage, predicting survival is essential to determine the treatment plan and place of care. However, it is often difficult to predict the survival of these patients owing to local tumor growth, which could lead to upper airway stenosis, hemorrhage, and reduction in oral intake. Conventionally, clinical prediction of survival (CPS), a subjective prediction of the prognosis by the attending physicians, is performed for predicting the survival in terminal-stage SCCHN patients. In general, however, CPS is not accurate and survival tends to be overestimated. In 2005, the European Association for Palliative Care recommended the use of prognostic tools in patients with advanced cancers. Since then, several prognostic tools have been developed for predicting the survival of patients receiving palliative care. In regard to reports of the use of these prognostic tools, most previous reports have focused on a variety of cancers, and few studies have reported specifically on patients with SCCHN. To clarify the current status of end-of-life care for SCCHN patients, we reviewed the data of SCCHN patients receiving care at Kagawa University Hospital in an end-of-life care setting. The median survival after the decision was made to provide best supportive care was 41 days (range; 0–206 days): 14 days in the “home care” group and 30 days in the “regional hospital” group. In another study on patients with SCCHN in an end-of life setting who were receiving care at Kagawa University Hospital or the National Hospital Organization Shikoku Cancer Center, the median survivals of the good, intermediate, and poor categories classified according to the status of Glasgow Prognostic Score (GPS) and Palliative Prognostic Index (PPI) were 127 (73–149), 64 (44–80), and 15 (9–27) days, respectively (p<0.05 among all categories). These results suggest that some prognostic tools might be useful for predicting the survival in terminally ill patients of SCCHN. However, further investigation is needed to clarify the usefulness of these prognostic tools for SCCHN patients.

We report three cases of central vertigo that were initially suspected as cases of acute peripheral vertigo at the department of internal medicine and by an otorhinolaryngologist, respectively. Case 1 was an 85-year-old man who presented with a history of rotatory vertigo and vomiting. A head CT revealed no abnormalities. He had positional nystagmus towards the left side, but no positive cranial signs. On the day after hospitalization, while his symptoms disappeared, the nystagmus persisted. Central vertigo was suspected. MRI revealed a cerebellar infarction in the territory of the left medial branch of the posterior inferior cerebellar artery. Case 2 was a 39-year-old man who presented with a history of rotatory vertigo and numbness in the left arm. A head CT and MRI revealed no abnormalities. He had spontaneous nystagmus toward the left side and also positional nystagmus towards the left side. On the 3rd day of hospitalization, the numbness in his left arm gradually spread to the left lower limb. Diffusion-weighted MRI performed about 56 hours after the onset of the rotatory vertigo and numbness in the left arm revealed right medial medullary infraction. The diagnosis in this case was difficult, because of the atypical features and the absence of abnormalities in the initial MRI. Case 3 was a 58-year-old man who presented with a history of rotatory vertigo. Physical examination revealed direction-changing ageotropic positional nystagmus. The patient was referred to our department by an otorhinolaryngologist with suspected benign paroxysmal positional vertigo (BPPV). CT showed left cerebellar hemorrhage. We should be aware of cerebellar disorder as a possible cause of vertigo in cases with nystagmus mimicking the pattern seen in BPPV.

Large-scale and detailed studies of sudden sensorineural hearing loss in children, which is extremely rare, remain scarce. Therefore, the pathophysiology, treatment, prognosis, and other aspects of this condition remain unclear. Moreover, no clinical practice guideline has been established. Over the past decade, we encountered two cases of sudden sensorineural hearing loss in children. Both cases were started on systemic steroid treatment, however, the hearing loss only progressed. Defibrinogenation therapy using batroxobin was adopted in combination with systemic steroids, which led to improvement of hearing in both cases. In fact, both cases showed complete recovery of their hearing in the low to middle range, although hearing in the high range remained impaired. Continued progression of the hearing loss under systemic steroid therapy alone, but recovery with the start of defibrinogenation therapy suggested that the pathophysiology involved insufficiency of blood circulation in the inner ear. We demonstrated the effectiveness of batroxobin in children presenting with sudden sensorineural hearing loss. Thus, defibrinogenation therapy with batroxobin may be an effective treatment option.

Lightning strikes, though rare, are associated with a mortality rate of 30%; but even when they are not fatal, they can cause lasting damage. The most commonly reported lightning-induced injury of the ear is tympanic membrane perforation. Although this type of injury sometimes resolves spontaneously, in severe cases the perforation persists.

A 41-year-old male patient was admitted to the critical care center at Tokyo Metropolitan Tama Medical Center after being struck by lightning while riding a bicycle in a thunderstorm. He lost consciousness temporarily and had dermal burn on the head, neck, and upper limbs on the right side. He complained of right hearing loss and ear fullness. Clinical examination revealed rupture of the right tympanic membrane, and an audiogram revealed conductive hearing loss.

The dermal burns were conservatively treated by a plastic surgeon, and the patient was discharged after 15 days. Although the audiogram showed slight improvement of his hearing with time, the tympanic membrane perforation persisted unchanged for 10 months after the injury, until a type I tympanoplasty was preformed to close the perforation. The patient’s hearing was completely restored by six months after this surgery.

Injuries from lightning strikes are rare, but otorhinolaryngologists should be aware of the potential for auditory impairment in such cases.

We report a case of pleomorphic adenoma of the nasopharynx that was extracted orally using Coblator^®.

A 63-year-old woman with ovarian malignancy was identified by CT, during a systematic examination of the whole body, as having a mass in the nasopharynx. There were no subjective symptoms pertaining to the otorhinolaryngological system. A vasodilated tumor with a smooth surface was seen in the mid-portion of the nasopharynx, towards the left side. A biopsy was performed to confirm the association of this tumor with the ovarian malignancy, and the findings were consistent with the diagnosis of pleomorphic adenoma. CT revealed mild, but uniform contrast enhancement of the entire tumor. MRI showed a contrast-enhancing mass measuring 21×22×22 mm in size in the posterior wall of the nasopharynx, visualized as a hypointensity in T1-weighted images and as a hyperintensity in T2-weighted images. As neither CT nor MRI showed any evidence of tumor infiltration of the surrounding tissues, resection of the tumor was planned. As the patient had telemetastasis to malignant ovarian tumor, the endoscopic transoropharyngeal approach was adopted for the surgery, to minimize the risk of postoperative dysfunction. Coblator^®, which is excellent for low-temprature resection, hemostatic coagulation and suction, was selected as the device for the tumor removal. The tumor could be successfully removed en bloc, with almost no bleeding. The patient was not particularly troubled by the hypernasality or tubal dysfunction. Although CT and MRI examinations conducted five months after the surgery showed no evidence of disease relapse, the patient unfortunately died of Trousseau syndrome caused by the ovarian cancer. Since the treatment was successful in this patient, we consider that it is important to choose a flexible treatment strategy according to individual cases.

We report the case of a patient who was diagnosed as having a subcutaneous abscess after bruise-related buccal trauma, in the absence of evidence of fracture/wound/foreign body insertion on imaging. Herein, we present the case with a review of the literature.

The patient was a 3-year-old girl. After sustaining a fall-related left buccal bruise/injury, she developed left buccal swelling. Examination revealed marked left buccal swelling/edema, suggestive of left buccal cellulitis. However, no fracture of the left buccal bone was found on computed tomography (CT) of the facial bones. Furthermore, ultrasonography early after the initial consultation did not demonstrate abscess formation. The patient was admitted on the same day, and started on intravenous antimicrobial drug therapy. Follow-up was continued.

Transient reduction of the left buccal swelling was observed by 8 days after the injury, but the swelling subsequently increased in size. The site of the swelling was punctured for drainage 12 days after injury. Culture of the abscess fluid grew Streptococcus pyogenes. Puncture/drainage and antimicrobial drug administration were continued, which resulted in improvement of the physical symptoms and inflammatory response, and the patient was discharged.

Although there was no fracture line on the facial bone CT, the results of abscess culture were consistent with those of pharyngeal culture on admission; therefore, it was considered that a hematogenous infection from sinusitis caused by a microfracture, which was not clearly visualized on imaging, or a buccal bone vascular perforation may have led to the formation of a subcutaneous hematoma, and subsequently, to the abscess formation.

We report the case of a child who developed a buccal subcutaneous abscess after sustaining trauma. This care emphasized the need for extra attention close monitoring to prevent progressive enlargement and exacerbation of the hematoma and formation of an abscess, as in the present case, after facial trauma. In this patient, fine needle aspiration was performed after consultation with a plastic surgeon. Considering importance of maintain an esthetic facial appearance in all age groups, including children, cooperation with other departments is needed during the treatment of such patients.

We report the treatment results of patients with ear canal cancer who visited the Department of Otolaryngology-Head and Neck Surgery, Kumamoto University, from December 2001 to August 2012. In T1 and T2 cases, a good prognosis was obtained by performing lateral temporal bone resection. On the other hand, T3 cases were given radiotherapy after lateral temporal bone resection and surrounding soft tissue resection, and T4 cases were considered as being inoperable and received radiotherapy combined with arterial CDDP injection. However, both T3 and T4 cases showed a poor prognosis.

Surgical treatment options for advanced cancer cases are limited. These findings suggested the necessity for expanding treatment options, such as radiotherapy combined with arterial CDDP injection or chemoradiotherapy combined with TPF for tumor shrinkage prior to surgical treatment.

We examined the preoperative diagnosis by fine needle aspiration (FNA), the postoperative histopathological diagnosis, the correct diagnosis rate, etc., in 84 cases of thyroid surgery performed from January 2016 to October 2018 at our hospital.

FNA yielded the diagnosis of malignancy in 13% of cases, suspected malignancy in 10% of cases, follicular neoplasm in 7% of cases, undetermined significance in 16% of cases, and benign lesions in 42% of cases. According to the postoperatinve histopathology, the diagnosis was adenomatous goiter (AG) in 33% of cases, follicular adenoma in 6% of cases, and malignant tumors, including incidental cancer, in 54% of cases. Comparison of the postoperative definitive diagnosis with the categories of FNA cytology showed that all the cases categorized as malignancy and suspicious for malignancy on FNA were definitively diagnosed as having malignancy. Among those who were categorized as suspicious for malignancy, 86% had malignant tumors and 14% were malignant lymphoma. Follicular neoplasms were diagnosed as follicular cancer in 17% of cases, follicular adenomas in 17% of cases, and AG in 50% of cases. In the combined benign and cyst fluid cases, malignant accounted for 31%.

Comparison of the ratios of benign and malignant pathologies after surgery revealed that all cases categorized on FNA as malignant or suspicious for malignancy were diagnosed as having malignant tumors, while some lesions categorized as benign by FNA were also diagnosed as malignant tumors. It is considered that in the FNA categories of benign and undetermined significance, the rate of diagnosis of malignancy on postoperative histopathology was high, because surgery was performed under the suspicion of malignancy. The accuracy, sensitivity, and specificity of FNA in our department were about 90%, 80%, and 100%, respectively, comparable to the results reported from other institutions. Since the specificity is extremely high, surgery should be considered only for the FNA categories of suspicious for malignancy or malignant. Even lesions categorized as benign or undetermined significance could turn out to be malignant. Therefore, it is important to conduct re-examination considering the finding of ultrasonography and decide the indications for surgery.

Dermatomyositis is sometimes associated with ectopic calcification in the skin and muscles, and can cause pain during movements, limited range of motion, skin ulcers, and/or local infections. We report a case of dermatomyositis in which ectopic calcification of the longus colli muscle caused injury to the external carotid artery. The patient was a 53-year-old woman with dermatomyositis who presented to the emergency department complaining of left cervical swelling that developed suddenly when she turned her neck to the right. After improvement of the swelling, the patient was admitted to our hospital with suspected injury to the external carotid artery caused by a calcified lesion, with bleeding from the lingual artery. The calcified lesion, which was found to be in the longus colli muscle, was resected. The bleeding was from the lingual artery. One year after the surgery, the patient’s condition remains satisfactory. Various conservative treatments have been used to treat ectopic calcifications associated with dermatomyositis, but no standard treatment has been established yet. If the calcified lesion is near an artery, as in this case, surgical treatment should be considered.

Neurofibromatosis type I (NF1) refers to neurofibromatosis associated with the presence of café-au-lait spots, and carries a relatively good prognosis. Pseudo-aneurysm formation in the head and neck region is relatively rare in patients with NF1, but could prove fatal by causing acute airway obstruction. We report a case of NF1 who presented with airway stenosis due to formation of a pseudo-aneurysm in the buccal region.

A 33-year-old man with NF1 presented with acute onset of swelling in the right buccal region. Computed tomography (CT) revealed a contrast-enhancing mass lesion measuring 4.0×4.0×7.5 cm in size in the right masseter muscle. Angiography showed an aneurysm of the maxillary artery, with extravasation of the contrast medium. The patient was admitted to the hospital and endovascular coil embolization of the aneurysm was performed by neurosurgeons. However, the facial swelling began to worsen gradually after about seven hours and bruising was found in the neck region. CT revealed re-bleeding in the right buccal region and tracheal deviation due to acute hemorrhage. Therefore, the patient was admitted to the ICU, intubated and initiated on mechanical ventilation. A repeat angiography showed a pseudo-aneurysm in the transverse facial artery, which was different from the pseudo-aneurysm treated earlier. This aneurysm had multiple feeding arteries, and was treated by coil embolization as well as embolized with N-butyl-2-cyanoacrylate (NBCA). Three days after the embolization, the patient was extubated and the postoperative course was satisfactory. No recurrence of the pseudo-aneurysms has been observed until date, more than half a year after the treatment. In patients with NF1 presenting with rupture of a pseudo-aneurysm in the head and neck region, prompt airway management is essential.

Poorly differentiated thyroid carcinoma (PDTC) shows histological and biological features intermediate between those of differentiated thyroid carcinoma (papillary thyroid carcinoma and follicular thyroid carcinoma) and anaplastic thyroid carcinoma. Skull base metastasis from thyroid carcinoma is rare. Herein, we report the case of a patient with PDTC whose presenting clinical feature was a skull base metastasis. A 69-year-old man who presented with a one-year history of headache was diagnosed as having a left-sided skull base tumor and referred to our hospital. Based on the findings at the initial examination, we suspected a middle ear paraganglioma invading the left clivus, posterior cranial fossa, sigmoid sinus, and jugular foramen. FDG-PET/CT revealed accumulation in the Th10 vertebra and also a small nodule with increased uptake in the right lobe of the thyroid, in addition to increased uptake in the skull base tumor. Biopsy of the skull base tumor was performed via mastoidectomy, and histopathological examination of the specimen revealed metastatic carcinoma from the thyroid with the following immunohistochemical staining profile: CKAE1/AE3+, CK7+, CK20-, PAX-8+, TTF-1+, and p63-. Total thyroidectomy was performed and histopathological examination of the resected specimen revealed the diagnosis of PDTC. Therefore, the patient subsequently also received radioactive iodine treatment. While skull-base metastasis from a thyroid carcinoma is rare, it is important to consider it in the differential diagnosis of a skull base tumor.

In recent years, the prevalence of sleep apnea syndrome (SAS) has increased, alongside that of metabolic syndrome.

The Japanese national health insurance system allows the use of continuous positive airway pressure (CPAP) therapy for patients with an apnea hypopnea index (AHI) of ≥40 recorded at home by an apnomonitor, even if polysomnography (PSG) has not been performed. Japanese otorhinolaryngology practitioners often follow-up patients with obstructive sleep apnea (OSA) on CPAP therapy. Intervention by CPAP is associated with a reduced frequency of apnea episodes, improved sleep quality, and also improvements in various associated symptoms. However, there are some reports of increased risk of development of central apnea (CSA), especially with advancing age, in patients receiving CPAP therapy for OSA.

According to the International Classification of Sleep Disorders, CSA can be classified into eight categories. We encountered a case in which CSA with Cheyne-Stokes breathing (CSA-CSB) appeared remarkably during CPAP therapy for severe OSA. Closer examination confirmed the presence of underlying atrial fibrillation with decreased heart function in this patient, and ablation therapy for atrial fibrillation performed by an interventional cardiologist resulted in improvement of the CSA-CSB. OSA serves as a risk factor for the development various diseases, especially cardiovascular disease, which is a highly prevalent comorbidity in patients with OSA. The risk of heart failure is increased and the risk of appearance of CSA, as a manifestation of heart failure, tends to increase with advancing age in patients with OSA. Otorhinolaryngologists engaged in the management of AHI and follow-up of patients on CPAP therapy, besides ensuring compliance, prescribing the optimal pressure for CPAP, and detecting any leakage, should grasp the general condition of the patient, especially paying attention to the presence of underlying cardiovascular disease, and should seek to collaborate with a cardiologist early in the clinical course. Appearance of CSA may be a sign of latent heart failure