Reanimation for facial palsy after resection of parotid gland carcinomas has been one of the most important issues for improving the quality of life of the patients. In the present article, we describe the current status of facial reconstructive surgeries after resection of parotid gland carcinomas. According to a nationwide questionnaire survey on facial reconstructive surgeries after resection of parotid gland carcinomas, primary reconstruction at the time of resection of the tumor is the basic policy in most institutions and plastic surgeons are involved in the facial reconstructive surgeries in 60% of the institutions. These results suggest that plastic surgeons play an important role in the reanimation for facial palsy after resection of parotid gland carcinomas including secondary plastic surgeries. We also discuss the methods for post-operative assessments of facial reconstructive surgery and show applications of the Sunnybrook facial grading system. Both head and neck surgeons and plastic surgeons should use a common method for post-operative assessments.

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Three reconstruction cases of total facial nerve plexus after radical total parotidectomy are presented. With nerve grafts, the facial-hypoglossal network was reconstructed using the end-to-side neurorrhaphy technique. Facial mimetic muscle function was improved, and postoperative ENMG findings showed double innervation of the mimetic muscles supplied by the facial and hypoglossal nerve.

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The increasing use of 3D treatment planning in head and neck radiation oncology has created an urgent need for new guidelines for the selection and delineation of the neck node areas to be included in the clinical target volume. “Whole neck irradiation”, in which total lymph nodes and the primary tumor are treated widely, is frequently necessary for the treatment of pharyngeal cancers since all pharyngeal tumors are likely to have extensive local tumor infiltration and wide lymph node metastases. However, it is important to pay careful attention to possible pitfalls in radiotherapy planning for the pharyngeal area, which consists of inhomogeneous materials such as soft tissue, bone, air, and metal. This paper presents the basic method and some pitfalls in radiotherapy planning, in particular for whole neck irradiation.

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In recent years, CT planning is commonly used for head and neck cancer. For supraglottic cancer, prophylactic irradiation of the upper and mid-jugular lymph nodes is recommended by the guide line in Japan. A large PTV and large fields of more than 100cm² are calculated using CT simulation for supraglottic cancer and Level II-III lymph nodes. Care is required for the high-dose area of the larynx using such large fields.
Some authors reported lower rates of neck node metastases using larger fields such as more than 50cm². In the era of X-ray simulation, we treated supraglottic cancer with a field size of 6 × 9cm² or more, and neck node metastases occurred in only 4% of patients without local recurrence. Fields larger than 100cm² based on CT planning may not be needed, and it is easy to deliver a homogeneous dose to the larynx using smaller fields of 6 × 9cm² or more.
For early glottic cancer, it is not necessary to apply prophylactic irradiation for regional lymph nodes. Some authors reported higher local control rates with larger field size. However, large fields are only used for local tumors, not for regional lymph nodes. We reported nodal recurrence of only 3% even for T2 glottic cancer using small fields of 5 × 5cm². Localized irradiation for primary tumor is preferred for early glottic cancer.
Head and neck cancer is a very important disease for radiation oncologists. These tumors can be controlled with radiation or chemoradiation without functional deficit. Radiation oncologists must diagnose head and neck cancers with the same level as head and neck surgeons.

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Information provided by modern cross-sectional imaging such as CT and MRI is essential for deciding the clinical strategy in tumor-staging, accurate tumor-mapping (mainly of deep extent), treatment planning and prognostic estimation of patients with head and neck cancer. In general, multi-detector row CT capable of obtaining whole neck images with high-spatial resolution is excellent for evaluating nodal staging and subtle cortical erosion of the skull base and jaw bones. On the other hand, high-resolution MRI is suitable for evaluating not only the extent of disease of the primary lesion of the naso- and oro-pharynges and oral cavity in the soft tissue and bone marrow cavity, but also intracranial extension (mainly of nasopharyngeal cancer). In this article, for each of the naso-, oro- and hypo-pharynges, oral cavity and larynx, representative imaging features and the clinical significance of important patterns of disease extent in squamous cell cancer are discussed.

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Thanks to significant progress in radiation treatment apparatus and treatment planning systems, intensity modulated radiotherapy (IMRT) has reached the stage of clinical application. Helical TomoTherapy (HT) is used for IMRT procedures: it facilitates quality assurance and ensures high clinical performance. Patients with head and neck cancer are ideal candidates for IMRT because they can clinically benefit from avoiding excessive radiation to organs at risk, and the radiation dose can be accurately matched to the target volume. It should be emphasized that IMRT can also preserve the function of the parotid gland, which is believed to correlate with quality of life after radiation treatment. IMRT also enables different radiation doses to be applied to each treatment volume classified according to clinical risk. HT also allows megavoltage CT images to be acquired during treatment courses, which can then be used to refine IMRT performance by improving the set-up and adapting the dose during the course of radiation treatment. Our initial experiences of IMRT using HT showed significant clinical benefits for patients with head and neck cancer.

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We evaluated the clinical outcome of 37 patients who had received intensity modulated radiation therapy (IMRT) in Hokkaido University Hospital from May 2002 to December 2007. Thirteen patients had nasopharyngeal cancer, 19 had oropharyngeal cancer, 3 had hypopharyngeal cancer, 1 had maxillary sinus cancer, and 1 had oral cancer.
One patient who had oropharyngeal cancer died of pharyngeal abscess which was a treatment-related complication. Three patients died of other cancers.
One patient with nasopharyngeal cancer had local recurrence. In patients with oropharyngeal cancer, recurrence at the primary site occurred in 3 patients, and residual/recurrence at neck lymph nodes occurred in 2 patients. One patient with hypopharyngeal cancer had residual neck lymph node metastasis.
Some patients experienced severe reactions to the radiation. One patient had pharyngeal abscess and died of this treatment complication. One patient who had nasopharyngeal cancer experienced hearing loss and angle closure glaucoma.

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In 2006, the Japan Society for Head and Neck Cancer made a declaration in which its members pledged to stop smoking and be moderate in drinking. In June 2008, our executive committee then sent a questionnaire concerning smoking to society members. The survey asked about smoking status, attitude toward smoking as medical doctors, awareness of the declaration and opinions regarding measures that could be taken to reduce smoking in order to improve health. The response rate was 32.9%. The proportion of doctors who had never smoked was 53.3%, those who had given up smoking 39.2%, and current smokers 7.1%. Most had been able to give up smoking on the first attempt. Many respondents said that doctors should not smoke and most of them felt that patients should be advised to give up smoking. The proportion of society members who were aware of our declaration was 74.3%. Most agreed that measures should be taken to make people think more about the health risks of smoking. Respondents hoped that there would be more public lectures on smoking, that the society would organize more sessions on the benefits of giving up smoking and being moderate in drinking, and that anti-smoking posters would be made.

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Thirty-two patients (23 males, 9 females) with maxillary sinus cancer were treated at Kyushu University Hospital during 2000-2008. They were classified by T classification as 5 cases with T2, 13 with T3, 12 with T4a, and 2 with T4b. Between 2000 and 2003, 16 patients were given irradiation, intra-arterial 5-fluorouracil (5-FU) infusion chemotherapy, maxillectomy and postoperative irradiation. After 2004, two patients with T4b maxillary sinus cancer were treated by superselective intra-arterial chemotherapy with Cisplatin (CDDP) and Docetaxel (DOC) and irradiation. Other patients were given irradiation and chemotherapy with S-1 and intra-arterial infusion of 5-FU. The 3-year survival rate was 68.3% for all patients. The 3-year survival rate was 74.6% for patients treated after 2004, whereas it was 62.5% for patients treated between 2000 and 2003.
Chemotherapy with S-1 or superselective intra-arterial chemotherapy with CDDP and DOC improved cause-specific survival rates.

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We performed a clinicopathological and immunohistochemical study of secondary cervical lymph node metastasis in stage I/II squamous cell carcinoma of the tongue. We investigated retrospectively 55 patients with stage I/II tongue carcinoma who were treated surgically from 1997 to 2006 at our department. Informed consent was obtained from all patients in this study. Fourteen of the 55 patients showed secondary cervical lymph node metastasis. To evaluate the activity of tumor cells of the primary site, we observed the expression of Ki-67 antigen at × 200 magnification, and calculated the Ki-67 labeling index. The high mark group significantly showed cervical lymph node metastasis in comparison with the low mark group (P = 0.024). Also, we performed immunohistochemical staining with D2-40 antigen to investigate the image of lymphatic vessel invasion and the number of peritumoral lymphatic vessels. Images of lymphatic vessel invasion were not observed, and we did not find a significant difference between the number of peritumoral lymphatic vessels and secondary cervical lymph node metastasis. It was thought that the Ki-67 labeling index could be used to predict secondary cervical lymph node metastasis.

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Purpose: To evaluate the significance of our dental management protocol by observing the chronological change of dental health of head and neck radiotherapy patients.
Patients and Methods: Fifty-two head and neck radiotherapy patients who had received dental management to prevent and/or alleviate their oral complications were enrolled in this study. They were followed for three or more years after radiotherapy. We divided them into three groups according to the timing of the start of dental management; Pre, Mid and Post. The chronological changes of dental status (DMFT and the number of tooth extractions) and osteoradionecrosis were investigated for three to five years.
Results: The increase in the DMFT index of the Pre and Mid groups was reduced to less than 2 by introducing our dental management protocol. On the contrary, the number of unavoidable tooth extractions following radiotherapy was the least in the Pre group. The incidence rates of osteoradionecrosis of the mandible in the Pre, Mid and Post groups were 6.5%, 18.0% and 20.0% respectively.
Conclusion: Our dental management protocol was proved to be effective in maintaining dental health and helpful in controlling osteoradionecrosis following head and neck radiotherapy. For a more effective outcome, we advocate that dental management should commence before the start of head and neck radiotherapy.

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Superselective intra-arterial infusion via the superficial temporal artery (STA) has become useful for oral cancer. Approaching via the occipital artery (OA) enables superselective intra-arterial infusion when catheter placement via the STA is impossible. Therefore, simultaneous catheter placement via the STA and OA is possible. We report a surgical method of simultaneous catheter placement via the STA and OA to achieve retrograde superselective intra-arterial infusion for gingival carcinoma of the mandible.
Preoperatively, three-dimensional computed tomography angiography was performed to identify the route of the external carotid artery and branches such as the STA, OA, maxillary artery, and facial artery (FA). Thirteen patients with mandibular gingival cancer underwent catheter placement via the STA and OA under local anesthesia. Catheter placement via the STA and OA was superselectively successful in all the patients. The mean operating time was 150.8 min. Catheter placed to the FA via the OA was dislocated during the treatment in one patient, and so the catheter was replaced. This method is useful to enable superselective intra-arterial chemotherapy to the whole gingival carcinoma of the mandible from the start of treatment compared with approaching via the STA.

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Since 1985, we have applied systematic treatment to improve radicality and postoperative oral dysfunction, as well as maxillofacial deformity. However, most T4 cases of oral cancer have remained difficult to treat, and diverse methods and results for progressive cancer have been reported by many institutions. For high-grade malignancy cases, we changed the treatment from bleomycin or cisplatin in induction chemotherapy to targeted intra-arterial infusions of carboplatin with radiation-combined therapy. In this study, we compared the effects of conventional therapy with targeted intra-arterial infusions of carboplatin for T4 cases of oral cancer.
Study design: In this retrospective review, we analyzed a subset of patients who were treated with induction chemotherapy using BLM and targeted intra-arterial infusions of CBDCA with radiation-combined therapy patients who received treatment between June 1985 and December 2006.
Results: Of the 105 patients who had T4 disease, the proportion with grade IIb to IV in the carboplatin with radiation-combined therapy (88.9%) was higher than that in induction chemotherapy (45.0%).
Conclusions: Targeted chemoradiation therapy followed by surgical salvage is a highly effective approach for the regional control of patients with T4, although additional strategies are required to address the problem of distant metastases.

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Patients with head and neck carcinoma are often provided concurrent chemoradiotherapy (CCRT), but they experience severe mucositis and dysphagia. These side effects can lead to decreased oral intake, resulting in interruption of treatment. In our hospital, from September 2007, all patients with oropharyngeal cancer who were to receive CCRT, were principally offered percutaneous endoscopic gastrostomy (PEG) before the start of treatment, and tube feeding was started when swallowing became impaired, to accomplish the treatment as planned. To evaluate the effect of prophylactic PEG, outcome measures in this study included the frequency of unplanned break from CCRT, nutritional deterioration and required analgesic during CCRT, complication of PEG, and patient satisfaction between 15 patients with PEG and 11 patients without PEG as a control group. Although no significant weight loss occurred in either group, there were fewer patients with a Body Mass Index < 18.5 in the PEG group after CCRT than in the control group. Regarding the treatment, most patients were satisfied with their PEG and considered that prophylactic PEG was necessary and helpful in completing the CCRT. This study suggests that prophylactic PEG helps patients to complete CCRT both mentally and nutritionally.

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We evaluated postoperative results in 41 patients (29 men and 12 women) who had undergone pharyngoesophageal reconstruction with free-jejunal autograft following total pharyngolaryngoesophagectomy in the Department of Otolaryngology, Head and Neck Surgery, Yamagata University School of Medicine from 1995 through 2005.
Postoperative complications and swallowing function were evaluated. Postoperative complications, including minor or nongraft-related, occurred in 29 of 41 (70.7%) patients. Serious complications followed by re-operation occurred in 15 (36.6%) patients. Six patients with graft failure underwent re-operation. The overall graft-survival rate was 85.4%. Graft strictured at distal anastomosis was the most common complication and was identified in 13 patients (31.7%). The incidence of graft stricture formation was not related with postoperative radiation. The incidence of graft stricture formation was greater in patients who received auto-suture than in those with Albert-Lembert suture (50% versus 9.1%, p = 0.0212). Therefore, we considered that auto-suture was one of the major reasons for graft stricture. We evaluated swallowing function in the 17 patients who answered the questionnaire. Fourteen patients (82%) noted malfunction in swallowing. Six patients (35%) were not satisfied with the present swallowing function. To improve swallowing function, it is necessary to consider further techniques of reconstructive operation.

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The purpose of this study was to investigate the effect of intraoperative treatment preventing Frey's syndrome, and especially to compare two techniques: sternocleidomastoid muscle flap (SCM flap) and simply suturing the remaining parotid capsule (suturing capsule). A series of 86 patients who underwent parotidectomy from 2002 to 2007 were asked by a questionnaire about the clinical symptoms of Frey's syndrome, and limitation of movement and pain at the lesion after parotidectomy. The postoperative period was no less than 12 months. The 58 patients who replied to the questionnaire were divided into two groups: SCM flap group (n = 29) and suturing capsule group (n = 29). The chi-square test was used to detect a significant difference between the groups. Regarding gustatory sweating, the percentage of patients answering “never notice the symptom” or “scarcely notice the symptom” was 93% (75 and 17%, respectively) in the SCM group and 96% (85 and 11%, respectively) in the suturing capsule group. Regarding flushing, the percentages were 93% (66 and 28%, respectively) in the SCM group and 93% (82 and 11%, respectively) in the suturing capsule group. There was no significant difference between the groups in terms of gustatory sweating or flushing. The difference in the number of patients who complained about limitation of movement or pain of the lesion was not significant between the groups, either. Deformity of the lesion was slightly more noticed in the SCM group, but without a significant difference (22% vs. 7%). We concluded that the SCM flap is an efficient method because it is as effective as simply suturing the capsule for preventing Frey's syndrome and can be used for wider defects of the parotid capsule.

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This case report describes the oral rehabilitation of a 67-year-old male patient using vertical alveolar distraction with dental implants because of a severely atrophic mandible after a marginal mandibulectomy was performed to treat mandibular gingival squamous cell carcinoma (T3N0M0, stage III). The vertical distraction was performed about 2 years after the tumor ablation surgery, and resulted in sufficient bone and soft tissue augmentation and successful dental implant placement. The bone-anchored implant prosthesis enabled better oral functional rehabilitation by the patient for 1.5 years after loading, without tumor recurrence or metastasis.

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Langerhans cell histiocytosis (LCH) is an extremely rare disease. The etiology of LCH remains to be defined, and the treatment of LCH has not been confirmed. We report three cases of LCH of the jaws. Case 1: a 14-year-old boy. LCH was recognized in the right molar region of the mandible. He received 10 Gy of radiotherapy and has had no evidence of disease for 8 years. Case 2: a 45-year-old woman. LCH was recognized in the bilateral molar regions of the jaws. Curettage and resection were performed, but some lesions recurred. An immunosuppressive agent was administered, and she has had no evidence of disease for 5 years. Case 3: a 38-year-old woman. LCH was recognized in the left molar region to the ramus of the mandible. Seven months after removal of the lesion, the disease recurred and she received 30 Gy of external irradiation. She has had no evidence of disease for 5 months. Long-term follow-up is necessary considering local recurrence of the disease and transformation into multifocal disease.

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A retrospective analysis was performed on 10 patients with adenoid cystic carcinoma in the head and neck, treated from January 1986 to January 2009 in Shimane University Hospital. The patients consisted of 3 females and 7 males, with a mean age of 58 years. The site of the lesion was the nasal cavity in 3, submandibular gland in 2, parotid gland in 2, oropharynx in 1, and external auditory canal in 2. The overall 5-year and 10-year survival rates as determined by the Kaplan-Meier method were both 60%. Two patients died of the tumor and 4 patients of distant metastases. When classified by histological grade reported by Szanto et al, 2 patients were grade I, 6 patients grade II, and 2 patients grade III. The prognosis deteriorated with higher grade. In addition, we immunohistochemically investigated the expression of Ki-67 protein positive cells. The Ki-67 labeling index ranged from 4.2% to 57.7%, and the average was 26.3%. The high rate group had a poorer prognosis than the low rate group. The Ki-67 labeling index was elevated in the high-grade components of histological grade of Szanto et al. We conclude that the Ki-67 labeling index is a powerful tool for predicting the prognosis for patients with head and neck adenoid cystic carcinoma.

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Mohs' chemosurgery was performed for a 48-year-old male with a metastatic lesion located in the skin of the retroauricular area of the external auditory cancer in order to control discharge, bleeding and pain from the lesion. The tumor was chemically fixed with fixative agent (Mohs' paste) and successive fixed layers were excised on 3 consecutive days until the cancer tissue-free plane was reached. The tumor decreased markedly in size accompanied by the alleviation of discharge, bleeding and pain from the tumor. The patient became completely free from distress, resulting in a marked improvement of quality of life. Mohs' chemosurgery may be useful not only for removing tumors but also for relieving refractory symptoms and improving patient's quality of life in the management of palliative medicine.

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