Simultaneous recording of laryngeal image, sound and voice analysis in one movie file has offered a convenient environment for medical examiners. However, it is not always gentle to the examinee or surrounding participants, including medical staff, due to limited audio-visual circumstances. We have developed a newly designed audio-visual environment for laryngeal examination with real-time voice and acoustic analysis displayed on multiple monitors under various platforms using the latest internet technologies: WebRTC and H.264, and Wi-Fi. In this new environment, anyone can watch the laryngeal image simultaneously using iOS (iPod touch, iPhone, iPad) or Android mobile devices at any place in the examination room.

The number of patients requiring home health care is on the increase, including bedridden patients and end-of-life patients in their last hours. The social demand for home health care calls for a prompt response. In order to meet this demand, multiple hospitals, clinics and visiting nursing stations have been closely coordinated to cooperate and complement each other in such home care management tasks. However, since the “training system for specified procedures performed by nurses” was implemented in Japan in October 2015, assistance in medical treatment by nurses has been limited. At the same time, there have been instances where the patient developed a lifethreatening situation, such as accidental withdrawal of a tracheal cannula. Behind the occurrence of such accidents seems to be a misconception of the training system for specific procedures performed by nurses. We, as researchers, have also been called on to maintain and improve the medical care technology of home health care doctors. The authors provide on-site training for doctors and nurses in charge of home health care concerning techniques necessary for tracheal cannula replacement and management. Here, we introduce our efforts to meet the needs of rural home health care.

We retrospectively reviewed 149 patients who underwent fine-needle aspiration for thyroid tumor between November 2012 and August 2015 at Japanese Red Cross Wakayama Medical Center and were found to have indeterminate cytology.

Sixty-eight patients (45.6%) underwent surgery; of those, the tumors of 29 patients (42.6%) were diagnosed as malignant. The most frequent type of malignancy was papillary thyroid carcinoma, while that of benign cases was adenomatous goiter, followed by follicular adenoma. Eighty patients underwent a repeat FNA. Repeat FNA results of malignancy or suspected malignancy were found in 7 patients. All 7 patients underwent surgery and 6 patients were found to have malignant post-operative pathology. Repeat FNA results were benign in 35 patients. Seven of those had surgery and 3 patients were found to have malignant post-operative pathology.

Overall, 45.6% underwent surgery, and the post-operative pathology malignancy rate was 42.6%. Even if repeat FNA results are benign, the possibility of malignancy cannot be ruled out completely. It is important to have careful observation for patients with indeterminate thyroid tumors, even if surgery is not performed.

Thyroarytenoid muscle paralysis, a form of partial laryngeal paresis, is regarded as a relatively rare condition. In general, the patient experiences breathy hoarseness due to glottal gap during phonation caused by bowing of the paralyzed vocal fold, even when laryngeal findings show the adductor and abductor movements of the vocal folds are normal. Laryngeal electromyography is necessary for a definitive diagnosis. Here we report four cases of thyroarytenoid muscle paralysis that occurred after general anesthesia. The patients complained of breathy hoarseness after surgery, but their vocal folds had normal adductor and abductor actions and bowing of the paralyzed vocal fold. We performed laryngeal electromyogram, and noticed the disappearance of motor unit action potential on the thyroarytenoid muscle of the paralyzed side. We diagnosed these cases as thyroarytenoid muscle paralysis. Three of the four patients were paralyzed on the right side and one patient was paralyzed on the left side. All four patients were followed up without medication, and their vocal fold paresis improved in between two months and four months (average: three months). It is thought that improvement can possibly be obtained only with several months of follow-up without medication.

In the acute phase of treating burn patients, assessing the presence of inhalation injury is an important factor to determine the therapeutic strategy. We suspect an inhalation injury when singed nasal vibrissae or soot in the upper airway is present, and checking the upper airway using a fiberscope is the most reliable examination to make the diagnosis. However, even when there are no typical signs suggestive of inhalation injury, at times, gradual worsening of the pharyngolaryngeal edema can cause upper airway obstruction leading to an emergency tracheal intubation, so careful observation at a high care unit is essential. We report such a case caused by exposure to high-temperature ethylene glycol. At first, there were no typical signs or symptoms of inhalation injury during the examination in the emergency room. However, within 10 hours after admission, late-onset regional pharyngolaryngeal edema causing upper airway obstruction occurred, and emergency tracheal intubation was performed. Seven days after intubation, pharyngolaryngeal edema improved, and the patient was successfully extubated. Our case patient's late-onset upper airway obstruction was caused not only by the immediate edema from the inhalation injury, but also by fluid shift after the facial and cervical burn. The regional edema that we observed may be related to the low tissue pressure of the pharyngolaryngeal mucous membrane, since we could observe a clear border between the edematous and non-edematous regions. Without question, patients with signs or symptoms of inhalation injury require tracheal intubation to keep the airway intact. However, even when there are no typical signs or symptoms of inhalation injury on the initial examination, we should be cautious of late-onset pharyngolaryngeal edema caused by fluid shift from the facial and cervical burn. Close and careful observation after a facial and cervical burn injury is highly recommended.

We report two surgical cases of spinal deformity that were at high risk of tracheo-innominate artery fistula in conventional tracheostomy management. In both cases, good clinical courses were obtained by devising surgical methods for airway securing. Case 1 was a case of tracheomalacia due to progression of scoliosis. A U-shaped sternum resection was performed to treat tracheal stenosis, and a central-part laryngectomy was performed simultaneously to prevent aspiration. Case 2 was a case of kyphotic deformity with high-level innominate artery. To relieve dyspnea caused by glottic cancer, cricoid fenestration was performed. Both types of surgery were minimally invasive and safe to perform.

Foreign body aspiration is a relatively common emergency in the pediatric age group. Pediatric bronchial foreign bodies can be treated as refractory pneumonia if acute-phase respiratory symptoms are missed, which cause chronic inflammation from a foreign body in the bronchus. One case was a 14-month-old female who presented respiratory distress and wheezing which developed while eating soybeans. She was diagnosed and successfully treated within 24 hours after aspiration. The second case involved a 19-month-old male who was brought for medical attention at a private clinic for a persistent cough which failed to improve through the use of prescribed antibiotics; later, after admission, a medical interview revealed that he had accidentally aspirated chocolate containing crushed almonds. Two weeks later, respiratory distress worsened, and he was examined by a pediatrician at a general hospital. Computed tomography revealed pneumomediastinum, subcutaneous emphysema, and hyperaeration of the left lung, which led the physician to suspect the presence of a foreign body or bodies in the left mainstem bronchus. The patient was immediately transferred and admitted to our hospital, where a bronchoscopy was performed under general anesthesia. As it was difficult to maintain adequate oxygen saturation with laryngeal mask ventilation and to identify the foreign bodies by rigid bronchoscopy, we performed a tracheostomy to insert a flexible video rhinolaryngoscope through the tracheostomy stoma, but failed to remove the foreign bodies due to severe intratracheal inflammation. We initiated antibiotic therapy to treat pneumonia and successfully removed the foreign bodies employing rigid bronchoscopy. We emphasize the importance of employing a careful treatment strategy in which repeated bronchoscopy is taken into account if intratracheal inflammation due to long-term retention looks severe on the first operation.