We examined 1714 patients who visited our hospital with chief complaint of a foreign body in the pharyngo-laryngeal and esophageal regions between April 2011 and March 2019. Foreign bodies were identified in 1040 patients(60.1%).The most common foreign body identified was a fish bone, and the most common site where foreign bodies were identified was the palatine tonsil. There was a significant association between subjective symptoms of odynophagia/pharyngalgia and the presence of a foreign body. The concordance between subjective symptoms in the right or left and the sites where foreign bodies were identified was greater than 90%.Of the subjective symptoms in the vertical dimension, 91.4% were in the palatine tonsil when the subjective symptoms were in the oral cavity. Complications were found in 4.6% of the patients. We assessed the factors that affected complications by multivariate analysis using logistic regression analysis. Age, injury period, the type of foreign body(denture),and the site of foreign body identification (esophagus)were the affecting factors in all cases where foreign bodies could be identified. Meanwhile, age, injury period, and the site of foreign body identification(esophagus)were the affecting factors when the foreign bodies were limited to fish bones. Confirming subjective symptoms may shorten the time to identify and remove foreign bodies as well as reduce the chances of overlooking them when diagnosing a foreign body in the pharyngo-laryngeal and esophageal regions, suggesting the importance of information obtained during medical consultation.
Percutaneous dilational tracheostomy (PDT) is commonly performed in intensive care units due to its shorter operation time and simpler surgical procedure than surgical tracheostomy (ST). We retrospectively assessed the surgical complications in patients who received a tracheostomy in our tertiary hospital between April 2016 and March 2018. In a total of 182 patients, PDT was performed in 25 cases and ST in 157 cases, in which the most common reason for tracheostomy was difficulty of extubation. The postoperative complications were wound infection in 12 cases, tube obstruction in 8 cases, prolonged bleeding in the wound bed in 6 cases, difficulty of incubation tube replacement in 4 cases, and granuloma in the airway in 5 cases. As for complications of PDT, we experienced 2 cases with severe surgical complications after PDT. One case suffered prolonged postoperative bleeding from the wound bed due to the granuloma around the trachea. The other case had severe damage at the anterior wall of the cricoid cartilage after cannula insertion. PDT in our hospital tends to be performed by the main department. In the 2 cases with severe complications after PDT we experienced, the first puncture site might not be appropriate. Therefore, ST is thought to be much safer in cases where cricoid cartilage and thyroid cartilage are difficult to identify from the body surface. Moreover, in order to perform the tracheostomy in safety, we recommend use of bronchoscopes or ultrasound during the procedure.
To identify the factors that influence the necessity of tracheostomy in patients with deep neck abscess who underwent an abscess incision, we performed physical examination, imaging investigations, etc. for 36 patients at our hospital. Tracheostomy was performed in 20 of the 36 patients. On preoperative contrast-enhanced computed tomography (CT) images, cases with abscess formation in any of the parapharyngeal space, visceral space, carotid space, or posterior pharyngeal space (referred to as the “specific 4 spaces”) were compared with those without abscess formation. There was a high rate of statistically significant laryngeal edema (p<0.01) and tracheostomy (p<0.01). Furthermore, with regard to the “specific 4 spaces,” a significantly higher proportion of patients with abscess formation in 3 or more spaces underwent tracheostomy compared to those with abscess formation in fewer than 3 spaces (p<0.01). On preoperative contrast-enhanced CT images, abscess formation in patients with deep neck abscess was noted in the visceral space, carotid space, posterior pharyngeal space that extends below the hyoid bone and is adjacent to the larynx, as well as in the parapharyngeal space, which is an important starting point for these spaces. Accurate assessment of the presence or absence of abscess formation in the “specific 4 spaces” was considered to be a measure of appropriate airway intervention.
Esophageal carcinosarcoma is a relatively rare histological type, accounting for 0 . 5 to 2 . 8% in esophageal malignancies. Here we report 4 cases of esophageal carcinosarcoma on which we performed thoracoscopic subtotal esophagectomy during the approximately five months from July 2017 to November 2017. All patients were male (mean age 76 years). One of the 4 patients was asymptomatic, and the other 3 presented dysphagia or cervical discomfort. Endoscopic examination showed type 0-I tumor in all patients. Based on pathological biopsy examination, 2 of the 4 patients were diagnosed with carcinosarcoma or suspected carcinosarcoma, and the other 2 were diagnosed with squamous cell carcinoma. Only 1 patient received preoperative chemotherapy with 5FU/CDDP. Thoracoscopic subtotal esophagectomy with extended lymphadenectomy was performed in all patients. The postoperative pathological diagnosis was carcinosarcoma with submucosal layer invasion in all patients. The only patient who received preoperative chemotherapy had station 2 lymph node metastasis. The average observation period is 2 years and 2 months, and all patients remain alive without recurrence at this stage. When we detect a pedunculated esophageal tumor, it is necessary to keep in mind the potential of carcinosarcoma, subject to careful examination. At the moment, there is no standard therapy for esophageal carcinosarcoma, but treatment based on esophagectomy with extended lymphadenectomy is considered appropriate.
Late one October, a 54-year-old woman experienced swelling and reddening in the left neck after taking cold medication. The following month, she underwent a check-up at our hospital by the ENT physician who had treated her previously. Although there was no typical focal oral and throat inflammation, she was diagnosed with left deep neck abscess based on clinical and computed tomography (CT) findings. An operation for abscess drainage was performed immediately. One month after reduction in inflammation, a lesion was suspected. A lateral cervical lesion was revealed on the CT scan taken during the first surgery. This lesion was removed in a second surgery the following month. It was a solid tumor with a film coating. Based on histopathological diagnosis, it was identified as lymph node metastasis comprising p16 positive squamous cell carcinoma. As her primary lesion was not identified in a positron emission tomography-CT scan, she was finally diagnosed with human papillomavirus (HPV) -associated oropharyngeal carcinoma based on the diagnostic criteria of the Union for International Cancer Control (8th edition). Six months after the first medical examination, she underwent left neck dissection and chemoradiotherapy. Based on our therapeutic experience and previous reports, we recommend that the possibility of occurrence of malignant lesions in cases of deep neck infections should not be ignored, even in the absence of typical focal oral and throat inflammation. Especially, if there is a single lesion in the cervical area, we should consider the presence of malignant tumors such as HPV-associated oropharyngeal carcinoma. Although clinical examination did not confirm the lesion as malignant, in this case, we administered treatment considering the lesion a malignant tumor.
An operating field for the tongue base is difficult to obtain compared to other areas in the head and neck. This can lead to a variety of post-operative problems, including those related to swallowing and articulation, and cosmetic aspects. Broadly speaking, there are three approaches to the tongue base: the oral approach, cervical incision approach, and mandibular osteotomy approach. The oral approach offers a narrow operating field, the cervical incision approach incurs risks of decreased swallowing functions and sutural insufficiencies, and the mandibular osteotomy approach has issues of invasiveness and cosmetic aspects. The median lingual approach with setback tongue flap for carcinomas in the tongue base is a surgical procedure that involves moving the front portion of the tongue on the affected side to the back, reconstructing the base of the tongue after a median incision from the tongue tip, and extracting the carcinoma. Mobility and blood flow of both the base and tip of the tongue can be preserved, although not completely. At our clinic, we investigated the use of TOVS in superficial carcinomas below T2, the median lingual approach with set-back tongue flap if deep invasions were suspected on image findings, and a combination of FK retractor or cervical incision approaches if the carcinoma had progressed to the caudal or lateral sides. We report cases under the treatment strategy of our clinic, where favorable results were obtained with regard to the functional, cosmetic, or curative aspects using the tongue median approach with set-back tongue flap or combined approaches involving the previous method and an FK retractor. Taking into account the extent of progression of the carcinoma and general conditions, the present method can be considered a surgical procedure that assures a radical cure and minimizes functional disorders.
Deep neck abscess, an infection spreading into the cervical connective tissue space and forming an abscess, needs to be treated immediately and appropriately, including surgical treatment. Deep neck infection sometimes progresses to descending necrotizing mediastinitis (DNM) due to gravity, respiratory movement and negative pressure in the thoracic cavity, and the mortality rate in such cases is 20-40%. Here, we report the case of a 25-year-old male who came to our hospital presenting with left neck swelling and sore throat. Computed tomography revealed a lowdensity area with poorly marginated and inhomogeneous contrast effect and gas produced mainly in the left submandibular space and left masticatory muscle space. He was diagnosed as having a left deep neck abscess. Tracheostomy and incisional drainage were performed. After surgery he was managed with mechanical ventilation and daily wound cleaning, and debridement was conducted under sedation and analgesia. He was weaned off mechanical ventilation on post-operative day 12 and was discharged on post-operative day 41. This case was at high risk of developing DNM because of extensive abscess around the tracheostomy and gas production. The results suggest that postoperative mechanical ventilator management for deep neck abscess may be useful for prevention of DNM.