Acid reflux and mucosal injury of the larynx, caused by vocal abuse, chronic cough and intratracheal intubation, may be involved in the development of laryngeal granuloma. However, the mechanism is unclear. An experimental rat model of gastro-esophageal reflux disease (GERD) was surgically created, and used to observe the histological changes of the laryngeal mucosa. However, no laryngeal granuloma had developed 20 weeks after surgery. This study developed an experimental laryngeal granuloma by mechanical injury to the vocal cord mucosa of the rat GERD model.
A plastic bar was inserted into the trachea of a GERD rat model, and moved up and down three times in three seconds, to mechanically injure the vocal cord mucosa. A granuloma was observed in the vocal cord mucosa of the rat after two weeks of the surgery, and this presented the same pathological structure as the human laryngeal granuloma. The current results showed both mechanical injury and acid reflux was involved in the development of a laryngeal granuloma.

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The aim of this study was to investigate the therapeutic effects of a combination of proton pump inhibitor (PPI) administration and vocal training on vocal abnormalities in laryngopharyngeal reflux disease (LPRD) subjects with both vocal cord inflammation and muscle tension dysphonia. Thirteen LPRD subjects (male 8, female 5) were enrolled and administrated rabeprazole (20mg) once a day. We conducted vocal training using humming on each subject every 4 weeks. We evaluated the degrees of vocal cord inflammation and supraglottic compression and vocal qualities during natural sustained vowel phonation and humming phonation at the first and final visits. In the first visit, all the subjects showed vocal abnormalities with more than 1 in the G score during natural vowel phonation. In the humming phonation, only 4 subjects showed less than 1 in the G score. In the final visit, only 8 and 4 subjects showed more than 1 in the G score and accomplished G0 in sustained vowel phonation, respectively. However, in the humming phonation, 12 subjects accomplished G0. These data indicate that while PPI administration improved the vocal cord inflammation, more than half of the subjects had muscle tension dysphonia even after the therapies. In addition, the humming method seems useful for estimation of `mixed voice disorders' due to both organic and functional factors.

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The etiology of glottic, subglottic and cervical tracheal stenosis includes congenital, inflammatory, traumatic and neoplastic diseases. The area of the stenotic lesion should be evaluated circumferentially and longitudinally. Endoscopy and CT scan present effective diagnostic information of the stenosis.
In a case with slightly stenotic lesion, T-tube insertion or transoral surgery is applied. In a case with severe stenosis, a cervical approach, either laryngotracheal trough method or cricotracheal resection, is applied. In the laryngotracheal trough method, scar tissue is removed and a stent is set into the groove. From three to six months after, reconstructive surgery using the auricle or costal cartilage is performed.
We developed an artificial trachea made of polypropylene mesh and collagen sponge which induced natural tissue regrowth and also elucidated the efficacy and safety of the method in an animal model. Based on approval of the Institutional Review Board (IRB), regenerative medicine of the cricoid and cervical trachea was clinically applied. There has been no re-stenosis in ten cases since 2002.

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Nasal airway patency plays a critical role in the pathogenesis of obstructive sleep apnea syndrome (OSAS). Recent studies have shown that nasal obstruction is an independent risk factor for OSAS and that its surgical correction generally has a positive impact on OSAS and its related symptoms. As the indication of nasal surgery for continuous positive airway pressure (CPAP) -intolerant OSAS patients suffering from nasal obstruction, nasal resistance is valuable. A value exceeding around 0.38Pa/cm³/sec in nasal resistance is thought to be suitable for nasal surgery for these patients. As the pharyngeal morphological indication of nasal surgery for OSAS patient suffering from nasal obstruction, nasal surgery is effective in those with a high-positioned soft palate and/or a wide retroglossal space. Regarding the effect of nasal surgery in the inferior turbinate, some papers indicate that submucosal resection results in the greatest increases in airflow and nasal respiratory function with the lowest risk of long-term complications.

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Cough is the most frequent symptom in the everyday outpatient clinic. It is important to grasp the nature of the cough and to diagnose the cause of the cough accurately as cough itself worsens the QOL of patients significantly. According to the duration, cough is defined as follows : acute cough lasting < 3 weeks, subacute cough lasting 3-8 weeks, chronic cough lasting > 8 weeks. In the differential diagnosis of prolonged cough, infection and chronic inflammation as infectious disease are the main causes of subacute cough, while asthma/cough variant asthma, gastroesophageal reflux disease, and psychological/habitual cough as non-infectious disease are other causes. Although in the differential diagnosis of chronic cough, cough due to drugs, interstitial lung disease, chronic sinusitis, and tumor/tuberculosis/foreign body in the trachea or the bronchus are the main causes, the frequency is not significant. History and physical examination of patients are still valid as diagnostic tools and have well-defined strengths and limitations.

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There is no clear consensus on the findings or clinical manifestations of laryngopharyngeal reflux disease (LPRD). Furthermore, there are no ideal diagnostic procedures for evaluating LPRD, and the diagnostic outcome criteria and treatment are ambiguous. The pitfalls of diagnosis and treatment for LPRD were discussed.
1) The symptoms of LPRD are protean and not specific for LPRD. 2) Transnasal videolaryngoscopy shows the suspected LPRD. However, it is difficult to evaluate the relationship between laryngopharyngeal acid reflux and LPRD with/without organic diseases. 3) Transnasal videoesophagoscopy often reveals the endoscopy-negative gastroesophageal reflux diseases (GERD) and LPRD. The pathological change at the gastroesophageal junction is not specific for LPRD. 4) 24-hour pH monitoring is both highly sensitive and specific for LPRD. Although, it remains a gold standard for the diagnosis of LPRD, there is no consensus with respect to the number of pH sensors, their location, or the interpretation of results from them. It is valid to use a pH level of 5 rather than 4 as indicative of laryngopharyngeal reflux. 5) Regarding the proton pump inhibitor (PPI) test, there are false negative LPRD cases. Examples include, in cases of LPRD being resistant to antacid therapy and LPRD with nocturnal gastric acid breakthrough on PPI therapy.
Pitfalls of LPRD should be taken into consideration when the diagnosis and treatment of LPRD are performed.

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The diagnosis and treatment of sleep-disordered breathing (SDB) in adults at outpatient clinics are described. In an outpatient clinic, morphological diagnosis and selection of treatment must be performed. The existence of SDB can be assessed and indication of treatment made based on oral consultation, X-rays, and morphological diagnosis of the nose, pharynx and larynx by fiberscope. By specifying the cause of SDB by morphological diagnosis, a patient's understanding deepens and motivation for treatment also improves. SDB diagnosis and a severity-of-illness judgment are performed using portable monitoring devices; Rather than automatic analysis, inspection analysis is recommended. When necessary, cooperation should be undertaken with hospital which can perform polysomnography. The treatment which can be performed at an outpatient clinic is mainly CPAP (continuous positive airway pressure). It is desirable to prepare two or more CPAP apparatuses. In an otolaryngology clinic which can treat the nose, the CPAP persistence rate is higher. Dryness in the nose caused by ventilation of CPAP should be monitored, and a CPAP humidifier added if needed. The CPAP usage should be checked by data, not only the apnea index and average usage time but also checking usage conditions and sleeping time, and instruction relating to sleeping habits should be added if necessary. If needed, cooperation should be undertaken with a hospital or dental clinic which can perform an operation or supply an oral appliance. Cooperation with a psychiatrist well versed in sleep disorders is also desirable. The role of an otolaryngologist is important in order to rates the accuracy of diagnosis and treatment of SDB.

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We are now in a super-aging society in Japan. When aged, we cannot avoid deterioration of the neuromuscular function, including swallowing. Thus, the increase in the incidence of dysphagic patients should be unavoidable. In our previous study, we reported that almost 30% of outpatients aged over 75 years visiting our ENT clinic showed signs of misdeglutiton in clinical examinations. Accordingly, increases in the incidence of bronchitis, pneumonia and suffocation associated with misdeglutition should be expected. Most pneumonia secondary to misdeglutition appeared to be due to aspiration of food. Proper clinical evaluation of the swallowing function followed by adequate instruction of food taking can lead to decreases in misdeglutition and its associated problems. It is very important for otolaryngologists to evaluate the swallowing function, since dysphagia can occur most frequently during the pharyngeal stage where endoscopic examination by otolaryngologists is quite useful.

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Historically, laryngeal surgery was performed using a head mirror, laryngoscope and laryngeal forceps under local anesthesia as one-day surgery. The surgical procedure has currently evolved into laryngeal microscopic surgery (LMS) under general anesthesia. LMS can be performed by a single operator, but because general anesthesia and hospitalization are necessary, it is difficult to perform in the clinic. By contrast, one-day laryngeal videoendoscopic surgery (LVES) can be performed under local anesthesia in the outpatient setting. However, a single operator cannot perform this procedure and an assistant is required. Also, LVES requires a special pair of forceps. We have developed a device that allows LVES to be performed by a single operator, with regular equipment, as same-day surgery in the clinic setting. We report herein on this device.
As the local anesthetic, we use only 2% lidocaine hydrochloride and 4% lidocaine hydrochloride during observation with a laryngeal fiberscope. Since this device requires the cooperation of the patient, informed consent is required before the procedure. Patients receive an explanation regarding postural changes (bending forward, humpback, jaw prominence), tongue position, and changes needed in the position of the head. Patients are told how changing the position of the head can make lesions on the vocal fold more accessible to forceps. Another feature of the procedure is operation of the endoscope with only the left hand, allowing the surgeon to operate the endoscope left-handed and at the same time manipulate the forceps with the right hand. This has enabled us to devise a procedure which does not use expensive special appliances. Through development of a device which can accomplish tracheal-esophageal procedures in the practical clinical setting, we have developed a LVES procedure allowing same-day laryngeal surgery in the clinic.

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Minimally invasive esophagectomy (MIE), including various techniques using thoracoscopy and/or laparoscopy, was developed 20 years ago. This study reviewed the literature to investigate the development of MIE and how it is evaluated at present. Transhiatal esophagectomy without thoracotomy was associated with fewer respiratory complications than transthoracic esophagectomy with extended en bloc lymphadenectomy. However, a trend toward improved long-term survival at 5 years was seen with the transthoracic approach. Thoracoscopic esophagectomy was performed with the aim of decreasing early postoperative morbidity and mortality to improve survival. Mediastinoscopic dissection in the upper mediastinum was reported by some authors. Outcomes of these procedures were reported from Western countries as one strategy against adenocarcinoma of the distal esophagus. In Japan, the most common pathology of esophageal cancers is squamous cell carcinoma. Decreased recurrence rate and improved prognosis have been obtained using radical mediastinal lymphadenectomy, particularly in the upper mediastinum. Radical mediastinal lymphadenectomy equivalent to open surgery was thus crucial during MIE when introduced to Japan. A recent meta-analysis has shown that patients undergoing MIE may benefit from reduced blood loss during surgery and fewer respiratory complications compared with open esophagectomy and equivalent survival compared to open esophagectomy. Controversy remains regarding the left lateral decubitus position or prone position as the optimal patient position, and use of robotic surgery now and in the future is gaining prominence as an issue. Anesthesia during artificial pneumothorax and benefits of physiological humidity around the organs during surgery should be investigated.

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Tracheostomy is carried out as an effective and life-saving procedure in the management of respiratory distress, and the percutaneous tracheostomy technique in particular has become increasingly popular over the past decade. However, morbid obesity or urgent tracheostomies are considered contraindications for percutaneous tracheostomy, and a conventional tracheostomy has been preferred when there are technical difficulties or difficult neck anatomy. Surgery in obese or short-necked patients is technically more difficult and associated with higher complication rates. The well-trained surgeon should be able to perform this procedure under urgent or difficult conditions. We should become experienced not only in the surgical procedure but also in postoperative care to prevent early or late complications.

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