We reviewed 35 cases of cervical esophageal reconstruction following total laryngopharyngectomy for advanced cancer at Hiroshima University Medical School (1980-1992). The incidence rates and causative factors of complications after pharyngo-esophageal reconstruction were analysed statistically. We used gastric tubes (2/35), deltopectoral (DP) flaps (14/35), and pectoralis major myocutaneous (PM-MC) flaps (19/35) for the esophageal reconstructions. Post-operative complications developed in 17 cases, such as flap necrosis, stenosis at the esophageal flap junction, and delayed fistulization. Four of these required readvancements of the DP and PM-MC flaps. The factors that could predispose for flap complications are age, preoperative radiation dose, choice of DP or PM-MC flap and the general condition of a patient. However, these factors did not show a significant positive correlation to the incidence rates of the complications in our study.
We found that site of the fistulae depended on the type of flap. In the case of DP flaps, the fistulae tended to occur at the site of the suture between the host skin and the flap as the bottom of the secondly reconstructed cervical esophagus. On the other hand, in the case of PM-MC flaps the site of the fistulae tended to be at the suture between the esophageal or pharyngeal mucosa and the flap skin.

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One way to evaluate hoarseness is through auditory impression. This method can not be performed by just anyone, for it takes an experienced examiner to evaluate the voice according to a set of given voice samples. However, an E. N. T. doctor is able to make a diagnosis of pathological voice quite accurately, with 70-80% probability, by hearing alone, whether or not he has special training in discriminating voice samples. Doctors do this subjectively, on the basis of past experience of the auditory impression of various symptoms and patient data such as age and sex taken into consideration. If there were a method in which a patient could evaluate his own voice in the same way as an experienced doctor without assistance, then such a method could be used as a screening test for voice disorders. We have employed fuzzy logic to calculate numerically such an auditory impression, we here report the development of a diagnostic method for such major disorders as cancer of the larynx (leukoplakia), vocal polyp, polypoid vocal fold, vocal nodule, unilateral laryngeal nerve paralysis and sulcus using fuzzy reasoning results obtained from questionnaires on voice. Using this method, we have been able to achieve approximately 60% accuracy of diagnosis.

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One case of tracheal diverticulum and eleven cases of bronchial diverticula were detected in 4127 subjects examined by fiberscopic bronchoscopy. The tracheal diverticulum was located in the right posterior portion of the trachea, and the bronchial diverticula were located in the right truncus intermedius (5 cases), the right basal bronchus (5 cases) and the right middle lobe bronchus (1 case). From our studies and reviewing the previous reports in Japan, we came to the conclusion that the frequent site of the tracheal diverticulum was at the right posterolateral portion and that of the bronchus was at the truncus intermedius. There was redness of the mucosa and vascular engorgement in 2 of the 12 cases of tracheobronchial diverticula. In most cases, diverticula were clinically silent, however in some cases, they tended to lead to the foci of inflammation. Therefore in case of the recurrent pulmonary inflammation, bronchofiberscopic examinations are highly recommended to rule out the tracheal or bronchial diverticula.

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A study on obstructive changes in airways and mucociliary clearance in children and youth with bronchial asthma was performed. Radioaerosol inhalation lung scintigraphies using ^99mTc-HSA (human serum albumin) were applied to 50 children and youth with bronchial asthma. The deposition patterns of the radioaerosol and aerosol clearance curves were evaluated.
Abnormal deposition patterns, which consisted of non-homogeneous distribution and/or hot-spot formation, were likely to be seen in cases with asthmatic attacks at the time of measurements. However, a few asymptomatic patients also revealed abnormal deposition patterns. The deposition patterns were related to FEV_1.0%, MMF, V₅₀ and V₂₅, but especially to FEV_1.0%.
As an index of mucociliary clearance, β, the rate constant of the ^99mTc-HSA aerosol clearance curve, was introduced. β was significantly lower in cases with abnormal aerosol deposition patterns than in normal ones. β was also significantly lower in cases undergoing asthmatic attack at the time of the measurements than in asymptomatic cases. β correlated negatively with FEV_1.0%, MMF, V₅₀ and V₂₅, but especially with FEV_1.0%. Although cases with long term affection or moderate-to-severe asthma, tended to reveal abnormal deposition patterns and had low β values, these differences were not statistically significant.
Radioaerosol inhalation lung scintigraphy with ^99mTc-HSA is useful for evaluating not only obstructive changes in the airways but also for evaluating mucociliary clearance in children with bronchial asthma.

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We use two types of management, operation and rehabilitation to improve dysphagia. However, it is not always easy to improve the swallowing function. If inappropriate foods and treatment programs are selected, patients might fail to improve in terms of the swallowing function, and the danger of aspiration pneumonia arises. For the patient's safety during swallowing therapy, all members of the dysphagia team (physician, swallowing therapist, nursing staff and dietician) need to understand the level of dysphagia.
In this study, we try to scale patients with dysphagia according to (1) amount of aspiration, (2) disability with regards to expectoration, and (3) level of unconciousness. We report that the rate of aspiration pneumonia during swallowing therapy has decreased using this scale.

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A case of pyriform sinus fistula of congenital origin was observed. The patient was a 36-year-old man who developed suppurative thyroiditis of the upper left lobe of the thyroid in 1985 and again in October 1988. He first visited our department on October 11, 1988. Two weeks later, on the basis of a barium esophagogram, a diagnosis of pyriform sinus fistula was made. In December, a total fistulectomy was performed. During the operation, the fistula was stained through the opening of the fistula canal under microlaryngoscopy. The fistula originated from the pyriform sinus membrane situated postern-superiorly to the inferior corn of the thyroid cartilage and descended to the superior pole of the thyroid through the caudal side of cricopharyngeal part of the musculus constrictor pharynges inferior. The lumen of the fistula canal was histologically lined with stratified squamous epithelium. The localization and the left-sidedness of the fistula canal suggested that it originated from the 4th branchial pouch.

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A case of bilateral vocal cord abductor paralysis in a patient with Parkinson's disease was reported. The patient was a 71-year-old male suffering from Parkinson's disease for four years. He developed dysphagia and stridor while walking one year ago. The authors filmed his larynx using a fiberscope during breathing, phonation and the pharyngeal reflex, and its movements were observed. The bilateral vocal cords showed severe bowing and were fixed in the midline. On inspiration, the vocal cords moved laterally only slightly. But once the pharyngeal reflex was evoked, just after the upward movement of the larynx and the strong adduction of bilateral vocal cords had ceased, the vocal cords moved laterally quite rapidly, and a near-complete abduction was soon achieved. Vocal cord abduction to such a degree was not observed during respiration at rest or during deep inspiration.
The fact that the potential for vocal cord abduction was preserved casts a doubt on an explanation of bilateral vocal cord abductor paralysis as atrophy of the nucleus ambiguus or as atrophy of the posterior cricoarytenoid muscle. Instead, we consider that our findings imply a rigidity of the laryngeal musculature and a simultaneous contraction of both the abductor and adductors, as contributing factors to the midline fixation of the vocal cords.

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Voice could be conserved by partial laryngopharyngectomy for hypopharyngeal carcinoma, but there have been problems in swallowing after this surgery. A partial laryngopharyngectomee with successful swallowing after use of a free forearm flap was reported.
A 52-year-old male with carcinoma of the hypopharyngeal posterior wall was classified as T2N0M0. The posterior wall, unilateral piriform sinus and one fourth of the thyroid cartilage were removed, and the pharynx was reconstructed with a forearm flap. The voice was normal and oral intake without aspiration became possible one month after surgery. Free forearm flaps were concluded as useful for reconstruction after partial laryngopharyngectomy.

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Esophageal foreign bodies can be removed relatively easily with a rigid or flexible endoscope, but external incision of the neck is sometimes necessary when endoscopic removal is difficult.
Case 1 was a 69-year-old female who noted a sore throat after swallowing a fish bone. A diagnosis of an impacted foreign body was made by plain X-ray of the neck, and the foreign body in the hypopharyngeal constrictor muscle was removed by external incision. Case 2 was a 53-year-old female who felt dyspnea from the day after swallowing a fish bone. Plain X-ray of the neck showed a marked thickening of the shadow of the postpharyngeal soft tissue. A giant hematoma was detected in the visceral fascia and resected by external incision of the neck.

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A case of papillary carcinoma in a remnant of the thyroglossal duct is reported. A 17-year-old female noticed a mass in the anterior neck about seven months prior to admission. A well circumscribed and elastic hard mass was palpated in the midline of the neck at the level of the hyoid bone. A thyroid scintigram showed normal uptake and normal location of the thyroid. Ultrasonography showed a multicystic lesion with a smooth surface and a slightly heterogeneous echo inside. Computed tomography revealed a well circumscribed mass with a mixed low-high-density area with partial calcification. The patient was operated on using Sistrunk's procedure. Histopathological examination showed a papillary carcinoma which had arisen in a remnant of a thyroglossal duct. The patient was postoperatively free from any evidence of recurrence for 30 months.

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The flexible fiberscope is today an indispensable tool for diagnosis and treatment under local anesthesia. However, even now, laryngomicrosurgery is the best way to remove small lesions of the larynx. When performing laryngomicrosurgeries under general anesthesia, full exposure of the true vocal cords in their entirety sometimes cannot be effected by direct laryngoscopy because of lockjaw or risks not foreseen prior to surgery, such as tooth injury. Insertion of a flexible fiberscope through a laryngoscope has enabled the removal of lesions by providing a clear view of the larynx.
This technique was considered quite adequate for safely removing small lesions in the laryngeal mucosa, such as polyps, without such side effects as fractures or loosening of the teeth in cases where full exposure of the entire larynx can not be effected by direct laryngoscopy.

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Two hundred eighty-six cases of tracheal and laryngeal diseases were treated with laser therapy for 13 years at our hospital. These included CO₂ laser operations in 178 cases, contact Nd: YAG laser operations in 100 cases, and non-contact Nd: YAG laser operations with flexible fiberscope in 8 cases. Non-contact Nd: YAG laser operations were useful in cases of tracheal (bronchial) tumors and stenosis. Contact Nd: YAG laser operations were valuable for open surgery (laryngectomy, radical neck-dissection etc.). Microscopic CO₂ laser operations were useful in cases of laryngeal diseases and especially laryngeal cancer (Tla). In such laser operations, the character of each laser operation must be considered in conjunction with the nature of the disease to be treated.

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