Patients with dysphagia under home care range from those who have difficulty in swallowing their usual meals to those who are unable to take their food orally and need tube feeding. Patients with dysphagia of varying degrees of severity are seen at local clinics. The purpose of this study was to clarify the characteristics of dysphagia in patients under home care and the features of dysphagia treatment in otorhinolaryngology clinics.

　A total of 361 patients with dysphagia who visited four otorhinolaryngology clinics in Kobe over a 11-year period from June 2008 to September 2019 were included in the study. We examined the interrelationships between the patients' form of meals, alternative nutritional methods, causative diseases, presence/absence of pneumonia, referring physicians, swallowing rehabilitation, and long-term care insurance certification.

　The results of our study revealed that in 137 of 361 cases (38%), the patients were not able to consume their conventional diet (so-called normal diet) orally; of the 137, 51 had a gastrostomy. Nearly half of the patients (166 cases)received referrals from home-related occupations.

　There were many cases of dementia, including those with underlying Parkinson's syndrome and cerebrovascular disorders. There were a number of cases in which the speech therapists visited the home as part of the visiting nursing about the rehabilitation at home.

　In home care, patients receive less nursing and care than during hospitalization. The role of the otolaryngologist is to provide outpatient guidance about the appropriate diet and eating style for each stage/severity of dysphagia. It is also important to provide appropriate rehabilitation and nutritional management at home, if necessary. This requires the cooperation of the patient's primary physician at home and other medical professionals in the community. In addition, collaboration with regional medical-related occupations is necessary, and especially for rehabilitation, it is often necessary to utilize long-term care insurance at home.

　Sialendoscopy was first reported by Katz¹⁾ in 1990, and is now widely used around the world as a treatment approach for submandibular gland sialolithiasis. A wide variety of treatment strategies for sialolithiasis have been described, making selection of the most suitable approach complex, including submandibular gland removal, transoral stone removal, stone removal by sialendoscopy, and combined sialendoscopy with transoral stone removal, in which an incision is made in the floor of the mouth under the guidance of sialendoscopy. While one of the greatest advantages of sialendoscopy is that no skin incision is necessary, it is difficult to decide upon sialendoscopy as the optimal approach, because of the experiences of difficult cases during operations. This study was aimed at drawing up a protocol for selecting the most appropriate treatment strategy for patients with submandibular gland sialolithiasis, while considering the merits and demerits of each treatment. According to a previous report, in 83.3% of patients who were 12 years old or younger, sialendoscopy alone was sufficient to extract the stone. Thus, there is no need to place any limitation on the age while selecting the appropriate treatment strategy. Transoral stone removal takes the shortest time for operation and anesthesia, and this is thought to be an advantage. Sialendoscopy alone appears to be sufficient for stone removal in cases with a minimum diameter of the stone of less than 3-4 mm. In regard to the location of the stones, in 88.2% of cases in which the stone was located close to the Wharton's papillae, the stones could be removed by sialendoscopy alone. For stones located at the hilum of the submandibular gland, it was more likely for the procedure to be converted to the combined approach or submandibular gland removal, because of incarceration of the stone or stenosis of the Wharton's duct. To identify cases in which it is necessary to adopt submandibular gland removal, we compared the group in which sialendoscopy was converted to the combined approach and the group in which it was converted to submandibular gland removal, in terms of the age, size of the stone, symptom duration, and presence/absence of acute infection; however, there were no statistically significant differences between the two groups. In consideration of these results, we drew up a protocol for selection of the most appropriate treatment strategy for individual patients at our hospital (Figure 5).

　Deep neck abscess (DNA) is a severe infection and requires early surgical drainage, as it can occasionally become fatal after progressing to descending necrotizing mediastinitis (DNM) or sepsis. The surgical incisions used for drainage are traditionally left open for postoperative drainage; the disadvantages of this treatment are that it involves the need for painful gauze exchange and washing by the patient, the open wounds are at a risk of developing secondary infection, and the treatment leaves cosmetically unseemly scars. In this study, we evaluated the usefulness of closed negative pressure drainage (CNPD), generally used in the field of head and neck surgery, for DNAs. We reviewed the data of 20 cases (16 men and 4 women; age, 4 to 86 years (mean, 54.5years)) of DNA treated surgically between March 2009 and March 2020 at Toyonaka municipal hospital. Four patients had diabetes mellitus and three had obesity. All cases were managed by CNPD after external skin incision. The skin was cut horizontally for providing cosmetic benefits after surgery. The site of the primary DNA was the tonsil (6 cases), pyriform sinus fistula (3 cases), or parotid gland (2 cases). The most frequently infected space was the parapharyngeal space, and two or more spaces were involved in 17 cases. The abscess extended to the infrahyoid region in 16 cases, including 3 cases in which it extended into the mediastinum. Streptococcal species and/or anaerobic bacteria were isolated from the abscesses and broad-spectrum penicillin was effective. As for complications, 3 cases needed re-operation and one case developed postoperative swallowing disorder; however, in all cases, the conditions resolved and the patients were discharged from the hospital. The mean hospital stay was 15.7 days (range, 9-43 days), which was shorter than in previous reports. CNPD is a useful treatment for DNA, in terms of the safety, ease of postoperative management, shortening of the hospital stay, and cosmetic wound healing.

　Although fine-needle aspiration cytology (FNAC) is generally considered as being a safe diagnostic technique for thyroid nodules, development of hematomas has been reported after FNAC of the thyroid. Antithrombotic therapy is a possible risk factor for post-FNAC hematoma formation. In addition, introduction of a variety of novel antithrombotic drugs in clinical practice recently and frequent revision of guidelines for the management of anticoagulant therapy in the perioperative period may have added to the confusion.

　Herein, we report the case of a 61-year-old male patient on anticoagulation therapy with rivaroxaban, one of direct oral anticoagulants (DOAC), who underwent FNAC for a left thyroid nodule; the procedure was followed by the formation and rapid expansion of a large neck hematoma, resulting in restricted vocal fold motions due to extramural compression of the lateral hypopharyngeal wall. To avoid fatal airway constriction and further expansion of the hematoma, the patient was intubated in the ICU, followed by surgical removal of the hematoma under general anesthesia, along with withdrawal of the anticoagulant. Postoperative computed tomography revealed a significant decrease in the hematoma volume, and the laryngeal narrowing improved.

　Recent guidelines for the management of anticoagulant therapy during the perioperative period recommend continuation of antithrombotic therapy to avoid the occurrence of thrombotic complications rather than place emphasis on the risk of hemorrhagic complications, although the final decision should be left to the attending physicians of individual cases. However, especially in the case of lesions of the neck, where hemorrhagic complications could possibly lead to fatal airway constriction, further consideration may be needed. We wish to emphasize the need for otolaryngologists to update their knowledge regarding novel antithrombotic drugs and their antidotes, and optimize the management methods for acute hemorrhagic complications.