We reviewed 97 patients with stage I and stage II laryngeal cancer who had undergone a combined therapy involving lasersurgery (CO₂ or KTP laser) and irradiation (LINAC, 2 Gy/fr/day, total 60-66 Gy) from 1988 to 1997. These patients included 88 with glottic cancer (T1a : 36, T1b : 20, T2 : 32), eight with supraglottic cancer (T1 : 3, T2 : 5) and one with subglottic cancer (T1) . The overall five-year survival rate was 82.8%, and the cause-specific-survival rate was 98.1%. The overall preservation rate of the larynx with the Kaplan-Meier method was 81.8% (stage I : 90.0% and stage II : 67.3%) . The preservation rates by subtypes were 95.5%, 80.4%, 71.6% and 58.3% for the glottic T1a, glottic T1b, glottic T2 and supraglottic types, respectively.
A post-operative estimation of phonatory functions under maximum phonation time (MPT) revealed that four out of 33 patients showed extremely poor functions (MPT < 6 s) . Two of these cases were caused by iatrogenic laryngeal webs on the anterior commissure. As a result, we concluded that the combined therapy in the present study was satisfactory for stage I and stage II laryngeal cancer except in cases of supraglottic cancer, cases with masses on the anterior commissure or cases with carcinoma in situ.

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MRI 3D images can be obtained by reconstructing 2D MRI sagittal view data owing to improvements in the analyzing capacity of the processing computers. We evaluated laryngeal endoscopic views using this technique.
One volunteer with a normal larynx and a patient with carcinoma of the larynx were examined. The specimen was scanned at 2 mm intervals without gaps, and the images from the laryngeal endoscopy were reconstructed.
The virtual endoscopic images were valuable in patient education and could be of help in evaluating pathological lesions and operation planning. This technique may be used more commonly in the clinical field in the near future as such thechnical innovations continue.

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We reviewed 442 (males : 248, females : 194) patients with recurrent laryngeal nerve paralysis (RLNP) at Ehime University Hospital from 1976 through 1996. Their mean age was 55.8 years ; that of the males was 57.8, and that of the females was 53.6 (p<0.05) . The affected nerve was unilateral in 400 patients (the right in 132 cases, and the left in 268) and bilateral in 42. The number of patients with postoperative RLNP was 181 (41%) . We also compared the results obtained from 1976 to 1985 with those from 1986 to 1996. The number of patients from 1976 to 1985 was 201 (males : 102, females : 99), while that from 1986 to 1996 was 241 (males : 146, females : 95) . There was a significant increase in male patients (p<0.05) . The number of patients with postoperative RLNP from 1976 to 1985 was 55 (27.4%), while that from 1986 to 1996 was 126 (52.3%) . There was a significant increase in patients with postoperative RLNP (p<0.01), which was caused by an increase in the number of cases who had had surgery for thyroid tumors and esophageal cancer. On the other hand, there was a significant decrease in patients due to chest diseases (p<0.05) . The ratio of idiopathic RLNP from 1986 to 1996 was lower than that from 1976 to 1985, but the difference was not statistically significant.

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The vertical movement of the vocal folds during phonation was analyzed using laser Doppler vibrometry (LDV) . Four excised canine and two human larynges were used for the study. A laser beam reflected from a LDV target on the upper surface of the vocal fold was fed into the LDV to measure its vertical velocity and displacement. A photoglottography (PGG) was simultaneously employed to follow changes in the glottal aperture during phonation. Signals from the LDV and PGG were recorded under three conditions : with and without vocal fold elongation, and with thyroarytenoid muscle (TA) contraction. Vocal fold elongation was obtained by cricothyroid approximation. TA contraction was attained by direct electrical stimulation. The vertical velocity and displacement increased as the mean airflow rate was increased. Displacement decreased when the vocal fold was elongated. On the other hand, the vertical velocity did not always increase when the vocal fold was elongated. When TA contracted, the vertical velocity and displacement increased.
By using the PGG output and the vertical displacement, we could investigate the changes in the trajectory of the LDV target in response to an increase in the mean airflow rate and in the contraction of TA. The LDV trajectory increased vertically and horizontally as the mean airflow rate increased. With TA contraction, the vertical change in the trajectory was much larger than the horizontal one.

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Parvalbumin (PA) is a small, water soluble, calcium-binding protein that is present in a limited number of vetebrate tissues. In skeletal muscle fibers, the concentration of PA is known to influence muscle relaxation speed and correlates with muscle fiber types. Fast-twitch fibers reveal a strong (type 2b) or intermediate (type 2a) reaction to PA anti-serum, while slow-twitch (type 1) fibers lack PA immunoreactivity. In this study, the distribution of muscle fiber types in the cricothyroid (CT), posterior cricoarytenoid (PCA), thyroarytenoid (TA), lateral cricoarytenoid (LCA), and inter-arytenoid (IA) muscles was determined in 8 cats using PA immunohistochemistry. Type 1 fibers occupied a large portion of the CT (60.7%) and vocalis (56.1%), in contrast to the predominance of type 2 fibers found in the lateral part of TA (75.9%), LCA (81.2%) and IA (77.8%) muscles. In PCA, although the majority of fibers were type 2, type 1 fibers still constituted 40% of the muscle fibers. The distribution of muscle fiber types in each intrinsic laryngeal muscle reflects the contractile properties that suit the physiological demands of each muscle, i. e., phonation in CT and vocalis, swallowing in the lateral part of TA, LCA and IA, and respiration in PCA. These results indicate that PA is a useful marker for determining muscle types in the intrinsic laryngeal muscles.

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Inflammatory reactions in the airway in which various inflammatory cells are involved play an important role in the pathogenesis of bronchial asthma. In particular, the activation of T cells and the accompanying role of cytokines have attracted attention. We employed peripheral mononuclear blood cells and lymphocytes from mite-antigen positive patients with bronchial asthma to investigate the production of various cytokines following stimulation with mite-antigen and the relationship between IgE-the most important factor in the pathogenesis of bronchial asthma- and cytokines.
The production of IL-1β, IL-2, sIL-2R, IL-3, IL-4, IL-5 and IL-6 from peripheral blood mononuclear cells (PBMC) following the addition of mite-antigen was determined by the sandwich ELISA method. The production of IL-1β, IL-2, sIL-2R, IL-3, IL-4, IL-5 and IL-6 in PBMCs was increased by stimulation with mite-antigen. When CD4⁺ and CD8⁺-enriched cell fractions were separated, the production of the cytokines IL-2, sIL-2R and IL-4 was elevated in the CD4⁺ T cells. IL-1β production from PBMCs increased in the presence of the CD4⁺-enriched cell fractions. Consequently, the effect of CD4⁺-enriched cell fractions in the production of IL-1β in mononuclear cells was considered.
The results of a determination of IgE production from PBMCs, using a highly-sensitive method, showed that IgE production increased following the addition of IL-4 to a level similar to that induced by stimulation with mite-antigen. The addition of either IFN-γ or anti-IL-4 reduced the amount of IgE increased by the addition of IL-4 or stimulation with mite-antigen. The addition of IL-2 further increased the amount of IgE production, which had been increased by stimulation with mite-antigen or the addition of IL-4, suggesting the importance of IL-2 in IgE production in B cells.
The results of our study indicate that mononuclear cells and lymphocytes, especially CD4⁺ T cells, are important for the onset of bronchial asthma as a Type I allergy.
In patients with bronchial asthma, CD4-positive T-lymphocytes are activated, and various cytokines are produced, following stimulation of PBMC with specific antigens. It is suggested that IL-4 and IL-2, which promote the production of IgE-the most important factor in I-type allergic reactions, might produce serious allergic reactions.
It is also concluded that the production of IL-3 and IL-5, which are considered to be cytokines activating eosinophils, is increased by stimulation with specific antigens which are potent inducers of further airway inflammation.
The above results suggest that various cytokines play an important role in the pathogenesis of bronchial asthma in their interactions with each other.

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A case who spontaneously extruded a hydroxyapatite block which had been implanted for the reconstruction of the trachea twelve years previously was reported. A 72-year-old female was admitted to the Kurume University Hospital complaining of dyspnea. Twelve years before, she had undergone a total thyroidectomy, bilateral radical neck dissection and partial resection of her trachea due to carcinoma of the thyroid gland. In addition, eight months after that surgery, for the reconstruction of tracheal defect, she underwent the implantation of a specially-designed hydroxyapatite block in her anterior neck.
A CT scan and laryngeal fiberscopy revealed that this apatite block had dislocated into the lumen, causing the stenosis of her airway. An emergent tracheostomy was performed and this apatite block was removed.
Electron microscopy revealed a partial destruction of the surface of this extruded apatite block, suggesting that this was one of the causes of the fragmentation. This destruction might have been due to an inflammatory reaction and/or long-term exposure to body fluids. The implantation of hydroxyapatite has been reported to be a safe and established technique in other fields. However, when used for the reconstruction of the upper airway, a surgically tight fixation of the hydroxyapatite block with tracheal cartilage seems to be required so as to histologically stabilize the block.

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Tracheobronchopathia osteochondroplastica is a rare disease first described by Wilks in 1857. In Japan, it was first described by Kidokoro in 1938. To date, about 370 cases of this disease have been reported in the world literature, while in Japan 140 cases have been reported. In the past, such cases were often diagnosed at autopsy, but an increasing number of patients with this disease are being diagnosed before death by bronchoscopy. The following is a report on a case of tracheobronchopathia osteochondroplastica.
A 42-year-old man had symptoms of dyspnea and loss of consciousness. Artificial respiration using a tracheal tube was instituted to improve consciousness. A tracheotomy was then deemed necessary. When the tracheotomy and cannulation was performed, the tracheal wall was found to be hard and ossified between the third tracheal cartilage and the subglottic space. White ossiferous nodular lesions were observed. Histopathological findings from a specimen of the nodular lesions showed submucosal bony and cartilaginous tissue covered with tracheal epithelium. CT findings revealed calcified nodules involving the anterior and lateral aspects of the tracheal and bronchial walls. Therefore, tracheobronchopathia osteochondroplastica was diagnosed.
To improve the tracheal stenosis between the tracheal stoma and the subglottis, we resected the nodular lesions with a Nd-YAG laser. Residual nodular lesions did not enlarge after this treatment, but the patient died from DIC.
Although this disease was been reported to be a very slowly progressing disease, our case showed a distinct progress within a short period. It was suggested that the rapid growth of the nodular lesions in this case was caused by physical stimulation. Therefore, we considered surgical and Nd-YAG laser treatments to be advisable for the excision of the nodular lesions in tracheobronchopathia osteochondroplastica.

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Esophageal perforation is a serious acute disease. In this paper, a case of esophageal perforation by a fish-bone with severe mediastinitis and a cervical abscess is reported.
For a 50-year-old male, the diagnosis was made 15 days after he had swallowed a fish-bone, because the symptoms were slight before severe chest pain began. Two esophageal perforations (19-21 cm and 24-31 cm from his initial tooth line) were confirmed by endoscopy. Moreover, mediastinitis and a huge cervical abscess were recognized perioperatively. Most of his esophagus was resected due to the two long perforations, and mediastinal drainage, cervical esophagostomy and gastrostomy were also performed. After the operation, the patient suffered from a severe pyothorax, but he fortunately recovered. 10 months later, an esophageal reconstraction by gastric tube was done. Since fish-bones sometimes cause esophageal perforations and severe complications are often seen, strict follow-up is needed for patients who accidentally swallow them.

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We report a rare case of toxic multinodular goiter. A 61-year-old Japanese woman had been healthy in her earlier years until she noticed a mid cervical mass at the age of 31. About 23 years later (1989), she began to experience tremors and palpitations. In September, 1995, she consulted a doctor after noticing an enlargement of her neck tumor. A cervical ultrasound examination revealed nodules in the right and left lobes of her thyroid. Endocrinological studies showed a suppression of TSH levels and an elevation of free T₃ and free T₄ levels in serum. Her illness was diagnosed as hyperthyroidism, and an antithyroid drug was prescribed. However, the drug was stopped after a few months due to side effects such as nausea and skin reaction. In a few months, her symptoms increased, and she arrived at our hospital in September, 1996. Several years earlier, in December, 1994, she had sought medical attention for general fatigue and had been diagnosed with chronic renal failure. She had required dialysis three times per week. After admission to our hospital in 1996, multinodular thyroid goiter was revealed by ultrasound and MRI examinations. Some of these nodules showed defect patterns on iodine scintigrams, and accumulation patterns on thallium scintigrams of the thyroid. A fine-needle aspiration biopsy of these nodules showed no malignancies. Autoantibodies such as anti-TSH receptor antibodies, the anti-thyroglobulin antibody, the anti-thyroid microsome antibody and the anti-thyroid peroxidase antibody were all negative in her serum. Therefore, she was diagnosed as having toxic multinodular goiter and subse-quently operated on for the nodules with a subtotal thyroidectomy. A pathological study revealed hyperplastic changes that were characteristic of adenomatous goiter. As such, this patient had had a very long asymptomatic period of 23 years before the manifestation of her hyperthyroidism.
This case suggests that we should clinically care for patients with non-toxic thyroid nodules for life, since it is distinctly possible that they will develop into thyrotoxicosis.

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