Type II thyroplasty is used as a treatment for adductor spasmodic dysphonia. The titanium bridge used in this surgery was first approved as a medical device in December 2017. The operative procedure is covered by Japanese national health insurance as laryngoplasty K400-3 (using a thyroid cartilage fixation device)，and it can be performed at medical institutions nationwide. Our department was an early adopter of this procedure in Japan, and since it was listed for insurance coverage in July 2018 we have performed it on 7 patients. We report that surgical experience here with a presentation of preoperative and postoperative voice findings and sound analysis. Significant improvements were seen postoperatively compared with preoperatively in the results of the voice handicap index, GRBAS scale, Mora method, and sound analysis. No serious adverse events were observed postoperatively. The advantages of type II thyroplasty are that it can be performed while conducting voice monitoring under local anesthesia, and that it is reversible, enabling readjustment if a problem occurs postoperatively. The long-term treatment effects have already been reported. In our cases the observation period was short, so we aim to continue follow-up observation. With good treatment outcomes and coverage by national health insurance, type II thyroplasty is predicted to spread nationwide in Japan as a general surgical treatment for adductor spasmodic dysphonia.

In Europe and America, tracheoesophageal (TE) shunt speech is commonly used for voice restoration after total laryngectomy because of the high acquisition rate of speech. As TE shunt speech does not need any specific training and produces a natural voice, its use in Japan is gradually increasing. In addition, it seems to be an appropriate option for voice restoration in the increasing number of patients presenting with head and neck cancer due to aging of the population. However, several issues related to the procedure still need to be resolved. To date, we have conducted the TE shunt operation with Provox voice prosthesis in 47 post-laryngectomy subjects. Among them, TE shunt closure was performed for three cases. We herein present these cases and considered the issues related to shunt surgery, especially in aged patients. We found that a multi-professional team approach should be adopted for supporting these patients, and continued care and follow-up should be provided by the ENT surgeons performing shunt surgeries.

The definition of poorly differentiated thyroid carcinoma (PDTC) has been changing over time. In Japan, there have been two definitions of PDTC, one decided by the Japanese Society of Thyroid Surgery (JSTS) and the other established by the World Health Organization (WHO)，and the two have often differed. JSTS first defined PDTC as differentiated thyroid carcinoma (DTC) with any poorly differentiated component in the 6th edition of its classification system (PDTC-6) in 2005. In 2015, its definition of PDTC was revised under the 7th edition (PDTC-7)，whereby the poorly differentiated component was required to exceed 50％，which conformed to the WHO's 2005 criteria. After this, in 2017 the WHO criteria adopted stricter conditions accepting the Turin proposal (PDTC-Turin)．Under these conditions, there have been few reports of PDTC case series in Japan. In this study, we report a case series of 20 thyroid carcinomas conforming to PDTC-6, poorly differentiated carcinomas, and differentiated carcinomas with poorly differentiated component under the current criteria. The patients were 5 males and 15 females, with a median age of 68 years old. There were 2 patients matching PDTC-Turin, 10 PDTC-7 (not matching PDTC-Turin) and 8 PDTC-6 (not matching PDTC-7)．The values of preoperative serum thyroglobulin were elevated in most cases. We experienced 8 cases with recurrence and most cases recurred in the condition of radioiodine scintigram negative and serum thyroglobulin negative. FDG/PET-CT was much more useful in detecting recurrent disease. Seven out of 8 cases died of the disease after recurrence, indicating near total failure of salvage therapy. The 2-year accumulated recurrence rate was 36％and 3-year overall survival rate was 65％．Recurrence and patient death did not seem to be related with pathological classification. We concluded that DTC with poorly differentiated component, even if it is not categorized as PDTC, should be treated with a strategy which is different from one treating DTC.

A foreign body lodged in the airway, causing choking, is an emergency situation that requires immediate treatment. Aspiration of a foreign body is common in children and the elderly, the most common foreign bodies being a peanut or toy in children, and a dental prosthesis in the elderly. Here, we report the very rare case of a spoon lodged in the airway. A 33-year-old female with anorexia nervosa self-induced repeated vomiting, and she swallowed the spoon accidentally. The spoon was lodged in the subglottis, and she immediately came to our hospital. We tried to remove it orally but without success. When her breathing worsened, we performed a tracheostomy under local anesthesia. We found the spoon located through the tracheostomy hole, rotated it 90 degrees, and successfully removed it orally. The tracheostomy was thought to be necessary both to keep the airway open and to carry out the procedure. A foreign body lodged in the larynx causes a critical condition. The selection of a proper removal method and consideration of immediate airway management are both of prime importance.

We present the case of a 77-year-old woman with complaints of difficulty in swallowing. She was diagnosed with esophageal cancer (MtLt, cT4bN1M0, cStage IVa) and underwent chemotherapy. After one course of chemotherapy, she developed an esophago-mediastinal fistula and mediastinal abscess, so she underwent esophageal stenting and was discharged；however, after discharge, she was unable to eat and was referred to our hospital. CT showed that the esophago-mediastinal fistula remained and esophagography revealed that the stent was not effective. Therefore, we performed esophageal bypass surgery for oral intake and removed the stent in anticipation of radiotherapy. The postoperative course was good. She started oral intake from postoperative day 11 and was discharged home on postoperative day 52. The patient survived at least three months without complications, although postoperative radiotherapy was not performed. Considering indications of the esophageal bypass, this could be more effective surgery than stent placement in patients with fistula formation without stenosis.

A 42-year-old male required airway management with tracheostomy retainer due to bilateral recurrent laryngeal nerve paralysis after total thyroidectomy and staged bilateral radical neck dissection. This case required four operations because of difficulty in airway management. He underwent left Ejnell's operation as the first surgery, but failed to maintain a wide airway. As the second surgery, he underwent right Ejnell's operation, and resection of the tracheostomal granuloma was also performed. However, because the tracheostoma shrank again, a third surgery was performed to enlarge the tracheostoma longitudinally, but this resulted in restenosis. As the fourth surgery, tracheostomaplasty was performed to create a zigzag-shaped suture line. As the result, tracheal stenosis did not recur and the patient could maintain the tracheostoma without cannulation. In this case, airway stenosis occurred at three levels : supraglottic, glottic, and tracheal. Ultimately, closure of the tracheostoma could not be achieved because of supraglottic stenosis. Meanwhile, tracheostomal stenosis repeatedly occurred because of excessive scar tissue, infection, chronic irritation by the tracheal cannula, and keloid history. We were able to prevent restenosis by making multiple triangular flaps and a zigzag-shaped tracheostoma which in turn reduced the wound tension.

The prevalence of late-onset myasthenia gravis (MG) has been increasing in recent years. Many elderly patients with MG do not exhibit typical clinical signs and symptoms. Elderly patients with MG often present with dysarthria and dysphagia but without eye muscle symptoms. Here we report the case of a 77-year-old man who showed subsequently progressing dysphagia during follow-up. He was found to have poor pharyngeal contraction and suspected to have neuromuscular disease. His blood analysis tested positive for antiacetylcholine receptor antibody and he underwent the edrophonium (Tensilon) test. As improvement of bulbar palsy was seen with the edrophonium test, he was diagnosed with MG.