Medical problems will increase in Japan, where the average age of the population is steadily increasing. We describe here diseases in the elderly and also their socio-medical environment.These include the introduction of current medical laws in Japan from a socioeconomic view-point, in addition to the physiological aging processes, the characteristics of diseases, the mental state of the elderly, home problems and nursing care systems. We stressed the necessity for medical administration from a wide view-point. A better understanding of these socio-economic problems may be very helpful in the practice of bronchoesophagology.

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The literature on laryngeal function in the speech of aged persons is reviewed. Two major techniques have been used for the study of utterances in aged persons; one uses isolated voice sounds and the other conventional running speech for analysis.
The former technique reveals aging-related changes in the vocal cords and in respiratory function. The voice of aged persons is characterized by hoarseness. That of males is also characterized by an increase in fundamental frequency, and that of females is characterized by a decrease. These changes are caused by an atrophy of the vocal folds in aged males and by an edematous change in aged females. However, this is only on among various aspects characteristic of the speech in aged persons.
Other changes includes changes in the articulatory system and its movements. Aging affects the mobility of the tongue, pharyngeal wall and soft palate. In the production of a plosive, for example, aging leads to low intrapharyngeal pressure and poor glottal opening. As a result, the speech of aged person tends to be less clear.
A combined study of isolated voice sounds and running speech is indispensable for the study of laryngeal function in aged persons.

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The effects of age on pulmonary functions were studied. The pulmonary functions include conventional pulmonary functions and the defense mechanisms of aspiration. Vital capacity and forced expiratory volume at one second decrease with age in subjects without smoking history. Defense mechanisms decreased markedly in elderly subjects with pneumonia, but were not decreased in healthy elderly subjects. Since pulmonary functions are not reversible, air pollution as well as smoking should be avoided as much as possible.

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Swallowing is one of the most basic of the behaviors needed to sustain life. Clarification of swallowing mechanisms in the elderly is essential from the viewpoint of the prevention and treatment of dysphagia. In the second stage of the act of swallowing, the afferent nerve fibers of the internal branch of the superior laryngeal nerve (SLN), which innervate the pharyngeal and supralaryngeal mucosa, are concentrated in the interstitial subnucleus (ni) of the nucleus solitarius. In senile patients, presynaptic nerve fibers responded to chemostimulation, such as pure water, and/or a pressure stimulus from a limited area of the base of the epiglottis, aryepiglottic folds and arytenoid region. Furthermore, cortical evoked potentials were recorded at the frontal part of the orbital gyrus bilaterally after stimulating the SLN. In this study, subjects over the age of 65 were recruited for analysis of their swallowing mechanisms using a newly devised manometric measuring apparatus for the oropharynx, hypopharynx and respiratory phases. The results were as follows: 1) The oro-pharyngeal coupling time (OPCT) was defined as the period (msec) from the production of the final pressure peak in the oropharyngeal propelling force to the maximum pressure peak in the hypopharynx during swallowing. In the elderly, this OPCT was prone to prolongation over 420msec. 2) The second purpose of this study was to correlate standard parameters from the viewpoint of videofluorescent analysis with the qualitative characteristics of liquid and semi-solid bolus transport in the elderly. This investigation was carried out by measuring individual viscosities of variable radio-opaque materials for use in angiography using a viscosi-meter. Viscosity was calculated as the shear stress divided by the shear rate. In the elderly, it an incoordination in terms of coupling time was found between the conveyance of the bolus to the hypopharynx in the oropharynx and the closing of the laryngeal vestibule.

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Pneumonia is the fourth leading cause of death in Japan. Elderly patients, in general, are prone to multimorbidity, atypical clinical symptoms, and show fewer symptomatic manifestations. Aspiration pneumonia in the elderly can be characterized by two aspects: asphyxia or airway obstruction, and microaspiration of oropharyngeal content. The latter occasionally results in bronchopneumonia, in which the inflammation extends from the upper respiratory tract to the smaller airways, and then to the alveolar regions. In this context, we have shown that the serum levels of secretory leukoprotease inhibitor (SLPI) are elevated in bronchopneumonia, making SLPI a useful serum indicator, particularly in the elderly.

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We have seen 53 cases of tracheoplasty in patients more than 65 years old. Fourty-nine cases (92.6%) involved neoplastic disease. The major diseases were thyroid cancer invading the trachea and lung cancer invading the lower trachea or tracheal carina. Only 11 cases out of the 53 patients required standard tracheoplasty with direct anastomosis between tracheal stomas after a circumferential resection of less than 7 tracheal cartridge rings. The remaining patients required specific operative modes of tracheoplasty which include laryngotracheoplasty (LT), terminal mediastinal tracheostomy (TMT), carinoplasty and tracheobronchial anastomosis (TB). The morbidity rate for postoperative complications was 14.7%, which was significantly higher than that in the total number of cases of tracheobronchoplasty which we saw.

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From 1998, 61 (11%) patients aged 74 years out of 558 patients who underwent esophagectomy for thoracic esophageal cancer were studied at postoperative pulmonary complications and anastomotic leakage were more frequent in aged patients than younger patients, especially pulmonary complications (p<0.05). However, the survival curve of the aged patients was nearly equal to it that of younger patients. In the 61 aged patients, 26 patients (group R) underwent esophagectomy through right thoracotomy, 28 patients (group L) underwent it through left abdominothoracotomy; and 7 patients (group B) underwent it without thoracotomy. In group R, pulmonary complications were more common than in group L (p<0.05). While in group R 3 (11.5%) patients died in hospital due to postoperative complications, no hospital death was found in group L. Esophagectomy through left abdominothoracotomy was thought to be a safe procedure compared to esophagectomy through right thoracotomy. The 5-year survival rate of group L (58%) was better than that of group R (42%), and no patients in group B survived for 5 years. Sternotomies performed in 6 patients in the L group did not exert much effect upon the postoperative course. It was concluded that esophagectomy through left abdominothoracotomy should be come a standard operative procedure for aged patients with thoracic esophageal cancer.

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To determine the efficacy of radiotherapy in treating laryngeal cancer, we investigated the gradation of the histological differentiation of squamous cell carcinoma in 333 patients with laryngeal cancer. Eighty-three percent of the supraglottic tumors were microscopically diagnosed as being of the moderately differentiated type, while 84% of glottic and 77% of subglottic tumors were diagnosed as the well differentiated type. In early glottic cases evaluated as being ineffective to primary radical irradiation, radio-resistant cancer cells were sometimes observed in the deeper area of the serial section of operatively resected larynges. The characteristic histological findings in cases of local recurrent early glottic cancer were considerable keratinization, invasion of the tumor into the surrounding tissue, fibrosis adjacent to the tumor, and the accumulation of a few inflammatory cells.

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Thyroplasty type IV (Isshiki) was performed in 6 patients with sulcus vocalis to improve hoarseness of voice. Improvement of their hoarseness by an approximation of the cricoid and thyroid cartilage with a manual maneuver was considered a good indication for the surgery. Voice was improved in all the patients operated on. The patients reported that their voice became louder and that it was easier for them to phonate after surgery. An objective voice evaluation showed a marked improvement in terms of auditory perception and acoustic analysis, though the amount of improvement was generally not so remarkable in the aerodynamic voice evaluation. In sound spectrogram, increase of harmonics in the middle to high voice range and the decrease of noise component were also noted after the surgery.

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A patient with multiple injuries in the pharynx and esophagus caused by a dog bite was discussed. Examination showed two perforations in the digestive organs: One was located at the left pyriform sinus and the other in the wall of the cervical esophagus. The sternocleidmastoid muscle, anterior cervical muscle, internal jugular vein and sympathetic nerve trunk were also invaded by the trauma.
If an injury to the esophagus is suspected it is usually necessary that diagnosis and treatment be done as quickly as possible. In this case, a esophagial injury was diagnosed at an early stage, because saburras were found in the avulsed wound to the cervical skin. There is usually a high possibility of multiple wounds and more serious subcutaneous damage compared to size of a lesion on the surface of the skin in dog bite injuries, and it is indispensable to understand all existinn wounds before beginning surgical treatment.

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