Due to its anatomical advantages in terms of proximity to the skin, and little comorbidity concerning vessels or nerves, the cricothyroid membrane (CTM) has been considered the first choice route to the airway in surgical airway management. However, fatal bleeding has been reported as one of the serious comorbidities arising from cricothyroidotomy/cricothyrotomy, so airway surgeons must be aware of precise anatomical features around the CTM. In this study, vascular anatomy as well as the size of the CTM were evaluated in Japanese cadavers. Seven male and 2 female cadavers were incorporated into the study. The cricothyroid artery originating from the superior thyroid artery was observed in 7 cadavers. All of these arteries were located in the upper one-third of the CTM, and a descending branch of the cricothyroid artery over the CTM was observed in 6 cadavers. Furthermore, the pyramidal lobe of the thyroid gland was located close to the midline of the CTM in 4 cadavers. The mean values of maximum width between the bilateral cricothyroid muscles in male and female were 12.3 mm and 9.5 mm, respectively. As for the vertical height of the CTM, the mean distances measured between the superior border of the cricoid cartilage and the inferior thyroid notch in male and female were 10.1 mm, and 9.3 mm, respectively. We believe that our results may aid airway surgeons in understanding vessel variation and anatomical size of the CTM in Japanese, for safe performance of cricothyroidotomy/cricothyrotomy.

Patients with head and neck cancer often develop a second primary esophageal cancer. In this study, we analyzed 48 cases with esophageal cancer after treatment for head and neck cancer, treated in our institution between 1995 and 2017. The incidence rate of second primary esophageal cancer after treatment for head and neck cancer was 3%, and 80% of these cases were diagnosed within 10 years after the diagnosis of head and neck cancer. There were no complications and no esophageal cancer deaths in the patients treated by endoscopic treatment. However, there were frequent complications in the patients treated by surgery and chemoradiation therapy, and these treatments were often limited due to head and neck cancer treatment. Over all 48 cases, the 3-year-survival rate was 44% and the 5-year-survival rate was 22%. Comparing those detected by follow-up endoscopy with those detected by symptoms, the follow-up endoscopy group were at an earlier stage of esophageal cancer (p=0.001), and had a tendency toward better prognosis (p=0.07). After treatment of head and neck cancer, follow-up endoscopy should be performed every year in order to detect any esophageal cancer at an early stage.

When performing tracheostomy on a pediatric patient, both the surgical technique per se and postoperative cannula management may give rise to issues. In particular, strict implementation of appropriate procedure is critical in the case of cannulation. Failure to do so may result in serious sequelae. Instructing and educating the patient on proper cannula management at home is very important, although procedures in the hospital ward are slightly different from those implemented after being discharged. However, the current approach may have shortcomings if even when appropriate procedures are performed, the patient experiences problems. In the past, we performed longitudinal resection for tracheostomy in a pediatric case. The patient had a cannulation accident, and the cannula was removed. Thereafter, we had difficulty in re-cannulation, and experienced accidental cannulation. Having learned lessons from this experience, we are currently using the technique developed by Fee-Ward in performing circumferential resection for tracheal fenestration when treating a pediatric patient who requires long-term cannula management. Fenestration enables safe performance of re-cannulation in all cases of a cannulation accident. By introducing fenestration, we minimized the incidence of issues. This paper retrospectively examines 115 pediatric cases who underwent tracheostomy at our department, with a focus on cannula management.

For patients with poor oral intake during treatment for head and neck cancer and patients with infectious diseases such as cervical abscess, we use a nasogastric tube and apply a liquid diet, which frequently causes diarrhea. Although several strategies such as changing diets with different administration speeds and specific gravities and antidiarrheal prescription are taken, their antidiarrheal efficacy is poor. Diarrhea impairs the quality of life (QOL) of the patients and the effort required of the caretaker is significant. Although semi-solid enteral nutritional supplements have been reported to prevent diarrhea, administration through the nasogastric tube is difficult due to their high viscosity. On the other hand, a viscosity-changing liquid diet which alters from liquid form to semi-solid form in the stomach can be administered through the nasogastric tube. The purpose of this study was to clarify the usefulness of a viscosity-changing liquid diet （Mermed One^®） for patients of head and neck diseases. We switched the liquid diet to Mermed One^® for patients with head and neck cancer and infections with diarrhea caused by liquid diet. The evaluation items were stool appearance, number of defecations, and the time of diet administration. In all cases liquid diet was administered through the nasogastric tube. In all patients stool appearance and administration time were improved after switching to Mermed One^®. These results suggest that a viscosity-changing liquid diet might be useful as an option for treating diarrhea due to liquid diet, and it may also be suitable as a liquid diet during chemoradiation for head and neck cancer. Preventing diarrhea and shortening the administration time may contribute to improving the QOL of patients and reducing the effort required of the caretaker.

We gained experience in performing a tracheostomy with lipectomy in a highly obese patient. The patient was a 46-year-old male, 170 cm, 155 kg (BMI 53.6). He is undergoing intubation management due to post-resuscitation encephalopathy after cardiopulmonary arrest. Because of the need for long-term airway management, the patient was referred to our department for a tracheostomy, and tracheal window surgery with lipectomy was performed. A T-shaped skin incision was made by transverse incision to the anterior margin of the bilateral sternocleidomastoid muscle at the base of the lower end of the cricoid cartilage and a longitudinal incision to the sternal process. The thyroid gland was split left and right following a standard mid-tracheostomy to expose the anterior wall of the trachea widely. After defatting the peri-tracheal foramen to be made (level I and VI areas), the anterior surface of the cricoid cartilage was resected using lüer forceps, and the anterior wall of the trachea was opened at the level of the cricoid cartilage. Postoperative airway management was facilitated by the tracheostomy with fat resection. Complications such as intratracheal granulation and brachiocephalic arterial fistula were prevented by using a high-level tracheal window and a flexible cannula (Adjust Fit^®).

Cervical necrotizing fasciitis (CNF) is a progressive soft tissue infection with relatively high mortality. Dysphagia is a known long-term complication of CNF. We report a case of a CNF patient who recovered from dysphagia after dysphagia rehabilitation. A 78-year-old woman was treated by debridement of necrotic platysma and surrounding soft tissue followed by split-thickness skin grafting. Although she had significant dysphagia (Penetration-Aspiration Scale : 7), she recovered and regained her ability to consume a normal diet after aggressive dysphagia rehabilitation. The rehabilitation involved activities such as oral movement training for impaired oral transit phase, tongue strengthening exercises, jaw opening exercises, cervical range of motion exercises for impaired laryngeal elevation, and tongue-holding maneuver for impaired pharyngeal contraction. To reduce the risk of dysphagia as a long-term complication of CNF, dysphagia rehabilitation should be recommended soon after surgery. Surgeons must avoid damaging nerves during surgery, and debridement should be performed only when necessary.

Adductor spasmodic dysphonia (AdSD) is local dystonia caused by involuntary contraction of the thyroarytenoid muscle during speech. The usefulness of type 2 thyroplasty (TP2) using a titanium bridge (TB) has been reported. The minimum standard size of the retailed TB is 2.0 mm, and it has been recommended that two TBs should be placed in the cranial and caudal sides of the space between the bilateral divided thyroid cartilages. We experienced a female patient with insufficient voice loudness after a long period since the performance of TP2. A female patient in her thirties presented with a voice break of speech and was diagnosed as AdSD. TP2 was performed, with a dilatation width of 2.0 mm in the space between the divided thyroid cartilages using two TBs. After the TP2, her speech disorder improved but she complained of weak voice for three years, and she came to us for a second TP2. Intraoperative findings showed nothing particularly amiss with the caudal TB ; the cranial TB was damaged at the left and right wing holes, but the width of the TB opening was maintained at 2.0 mm. After removing both TBs, voice deterioration was confirmed. In order to reduce the opening width to 2.0 mm or less, a TB with a widened width of 2.0 mm was used only on the caudal side. The width of the dilatation was 2.0 mm on the caudal side, about 1.5 mm at the anterior commissure, and about 1.0 mm on the cranial side. The mora method was 0/21, G0. Voice volume increased and was maintained for 14 months after the reoperation. It is standard procedure to use two TBs. However, by using a TB with a dilatation width of 2.0 mm only on the caudal side, we were able to reduce the dilatation width to less than 2.0 mm. It is not recommended to use one TB, although it was considered to be a useful method when the width of the dilatation is too wide even at 2.0 mm after revision type 2 thyroplasty.