In Japan, swallowing disorders have increased as the nation becomes a “super-aged” society, making treatments of such disorders indispensable. The video-endoscopy (VE) method developed by Hyodo et al. is useful for evaluating swallowing functions. I classified cases of swallowing disorder by degree of severity and presented treatment methods for each classification. As a rule, I introduce the most serious cases to a specialized institution. Because swallowing disorders derive from systemic diseases, a physician should take the lead in providing treatment. The proper approach is necessary in each case, dependent on factors including the patient's overall physical state, mental state, breathing, nutrition, movement activity, oral health, digestive state, etc.

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In order to determine the optimal therapeutic strategy for cervical esophageal carcinoma, it is important to determine whether or not the larynx can be preserved. In our institute, we aggressively preserve the larynx even when the oral side of the tumor margin extends beyond the esophageal orifice. The “tracheal traction method” is a maneuver where the trachea is moved forward with the larynx and hypopharynx, while the “larynx rotation method” is a method where the larynx and hypopharynx are manually rotated counterclockwise more than 90 degrees by holding down the thyroid cartilage. Such maneuvers provide a sufficient surgical field to transect the cervical esophagus on the oral side of the tumor and to anastomose it with a substituted organ. Here we describe the clinical results of seven patients who underwent this surgical procedure. The mean distance from the esophageal orifice to the tumor was 0.6 cm, and tumor invasion beyond the orifice was observed in two patients. Regarding morbidities, six patients temporarily demonstrated unilateral recurrent nerve palsy, while one had bilateral nerve palsy. Mild aspiration pneumonia and dysphagia were observed in some patients. During the median postoperative follow-up period of 881 days, no patient has so far shown any recurrence on the oral side of the anastomotic line. This surgical procedure may improve the clinical outcome of patients with cervical esophageal carcinoma, because it may be a preferable option for some patients who might refuse surgery due to a fear of losing their voice. New methods for the resection and reconstruction of the cervical esophagus are therefore needed to better preserve the swallowing function.

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In our institution, no planned neck dissection (PND) is performed on patients of hypopharyngeal carcinoma treated by concurrent chemoradiotherapy (CCRT). The metastatic cervical lymph nodes are evaluated when patients receive CCRT, and we determine whether neck dissection (ND) is needed or not. If ND is not necessary, we then perform ND if recurrence is observed. The present study examined the validity of these treatment methods. The subjects were 14 hypopharyngeal carcinoma patients treated by CCRT for neck lymph node metastasis ; they were followed for at least a year. All patients were male. The mean age was 65 years old and the mean follow-up period was 32 months. The primary sites were the pyriform sinus in 10 patients and posterior wall in the other 4. As to disease stage, 2 were stage III and 12 stage IV. The CCRT outcomes with respect to lymph nodes were CR in 7 and PR in 7 patients. Salvage neck dissection (SND) was performed on 4 sides in 3 patients. There were no complications due to ND. No recurrence was found in 6 of the 14 patients. Ultimately 7 patients died due to hypopharyngeal carcinoma and 1 patient due to colon cancer. Sites of recurrence/metastasis were the primary site in 3 patients, cervical lymph nodes in 3, retropharyngeal lymph nodes in 2, mediastinal lymph nodes in 1 and multiple organs in 3 (including duplication). The cervical lymph node control rate was 79%. We considered the above results as confirming the validity of our treatment strategy.

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Cricothyrotomy is often performed by surgeons, anesthetists or emergency physicians, in addition to otolaryngologists. Complications of cricothyrotomy are reported to include wound bleeding, emphysema, granulation caused by tube misplacement, and subglottic stenosis. Here we report a case of vocal cord paralysis caused by misdirected cricothyrotomy. An 82-year-old male underwent aortic valve replacement performed by a cardiovascular surgeon. Cricothyrotomy was required for sputum retention after surgery. With recovery of respiratory function, he was referred to our department for swallowing evaluation by an otolaryngologist. Laryngeal endoscopy showed bilateral vocal cord paralysis and penetration of the right vocal cord by the intubation tube. Computed tomography showed the intubation tube penetrating through the thyroid cartilage and right thyroarytenoid muscle. Tracheotomy was performed for decannulation of the intubation tube. After 3 months' observation, the bilateral vocal cord paralysis had not improved. The right vocal cord paralysis was assumed to be caused by the misplacement of the intubation tube, and the left vocal cord paralysis by aortic aneurysm or aortic surgery. Whereas subglottic stenosis after cricothyrotomy is occasionally reported, vocal cord paralysis is rare. Complications of cricothyrotomy should be prevented by inserting the intubation tube in the correct location and avoiding long-term intubation.

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It has been reported that fatal complications associated with influenza include unexpected cardiopulmonary arrest as well as pneumonia, encephalitis and myocarditis. Here we report three cases with life-threatening epiglottic abscess that developed shortly after diagnosis of influenza. Case 1: A 45-year-old male visited a primary-care physician with a sore throat and was diagnosed with influenza B using a throat swab. A few hours later, breathing became difficult and he called for an ambulance. An emergency medical team found him in cardiopulmonary arrest at home. Case 2: A 62-year-old male with fever and dysphagia was diagnosed as influenza A and administered the neuraminidase inhibitor zanamivir. Breathing difficulties appeared several hours later, during the night. Case 3: A 53-year-old female with a sore throat was diagnosed as influenza B and administered the inhaled neuraminidase inhibitor laninamivir octanoate. The sore throat was resolved after several days but dyspnea reappeared four days after the diagnosis of influenza. In all three cases, flexible fiberscopy revealed a swollen epiglottis with an abscess that had almost completely closed the upper respiratory tract. We believe that acute epiglottitis can be a fatal complication in patients infected with influenza virus. It is recommended to assess the presence or absence of signs and symptoms of airway constriction in physical examination of patients with influenza. It is also important to give instruction to patients to return to the clinic if respiratory distress develops.

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Acute epiglottitis is often observed in daily clinical practice, and in rare cases it runs the risk of causing death due to airway obstruction. In such cases, it is necessary to open the airway as swiftly as possible. However, in severe cases, it is very difficult to maintain an open airway because it is impossible a) to see the vocal cords directly owing to swollen mucous membrane and b) to set the patient in a stable supine position due to dyspnea. Here we reported three acute epiglottitis cases that required maintenance of the open airway by surgical neck incision in spite of the impossibility of securing a supine position. We recommend preventive airway maintenance for acute epiglottitis before it becomes severe, because it is very difficult to open the airway in an emergency. In an emergency, above all it is vital to maintain an open airway. Once this becomes possible, rapid treatment is then required to decrease aftereffects. It is necessary to regularly prepare emergency measures for airway stenosis due to acute epiglottitis.

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Pyriform sinus fistulas arise from disturbances in the development of the fetal fourth branchial pouch. Mostly they are found on the left side. Here, we report a rare case of a right-sided pyriform sinus fistula. An 8-year-old boy presented with right neck pain and fever. Enhanced computed tomography showed a low-density area around the right thyroid lobe. He was diagnosed as having acute thyroiditis and was administered antibiotics. Barium swallow was performed three times and showed a right-sided pyriform sinus fistula. An operation was performed under general anesthesia. The fistula opening was located by direct hypopharyngoscopy and blue solution was injected. A fistula extending to the thyroid was identified by a cervical approach. The fistula and part of the right thyroid were removed.

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We report a case of airway obstruction due to aspiration of oral mucosal residue. The patient was a bedridden 73-year-old male with a previous history of cerebral infarction. He was admitted to our hospital for treatment of urinary tract infection. On the 20th day in hospital, productive cough occurred suddenly after oral care and severe hypoxia developed. CT showed an obstructive mass in the right truncus intermedius. Bronchoscopy was performed for diagnosis and treatment. The right truncus intermedius was obstructed by oral mucosal residue. It was removed bronchoscopically, and the oxygenation of the patient was improved after the bronchoscopic treatment. Therefore, for some elderly bedridden patients in whom aspiration of a foreign body or sudden dyspnea is not indicated, medical staff need to be aware of any change in the patient's appearance and to suspect aspiration of a foreign body.

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