Patients with hypopharyngeal cancer are well known to often have multiple primary cancers, including, in particular, esophageal cancer. Radiotherapy is not suitable for the treatment of hypopharyngeal cancer if the patient has already received irradiation for esophageal cancer. Therefore, we regard partial pharyngectomy as a very important strategy for the purpose of laryngeal preservation in patients with hypopharyngeal cancer.
We use one of two techniques for laryngo–pharyngeal surgery.
The first is endoscopic laryngo-pharyngeal surgery (ELPS), conducted in cooperation with a gastrointestinal endoscopist as a minimally invasive surgery. We have shown that it is a useful technique for patients with superficial pharyngeal cancer. Pharyngeal expansion using the curved laryngoscope is very useful for improved observation, and the extent of spread of the lesion is determined by gastrointestinal endoscopy. We have performed over 100 cases of ELPS since 2007, and the 5-year cause-specific survival rate is approximately 98%.
The second technique is laryngeal preservation surgery, for cases with invasive hypopharyngeal cancer. We have performed laryngeal preservation surgery in 46 patients since 2004. Recently, for more precise resection, we determined the extent of resection by endoscopy and performed a mucosal incision. Then, we removed the tumor via a cervical approach. Using this method, we achieved complete resection in all cases, as confirmed by postoperative histopathological examination. The 5-year cause-specific survival rate is approximately 90%.
The number of patients suffering from cedar pollinosis is increasing. It would be no exaggeration to say that it is the unique cause of allergic rhinitis in Japan. Allergen immunotherapy has recently attracted attention as a radical treatment for cedar pollinosis, just as for allergic rhinitis. We examined cedar pollinosis was more marked in the cypress season than in the cedar season. The present study included 27 patients who had received allergen immunotherapy for cedar pollinosis for more than a year. A questionnaire survey was also conducted on drug usage according to the Japanese Allergic Conjunctival Disease QOL Questionnaire (JACQLQ), a modified version of the Japanese Allergic Rhinitis Standard QOL Questionnaire.
In 2015, the amount of scattered pollen was 1660.7/cm2, being lower than the average of the past 20 years. In patients who had received immunotherapy against cedar pollinosis regardless of the duration of the therapy, the nasal and eye symptoms, medication score, and face scale were worse in the cypress season. In addition, tests for allergn-specific IgE antibodies before and after the cedar/cypress seasons demonstrated that while the cedar-specific IgE levels did not increase, the cypress-specific IgE levels significantly increased in subjects who had received immunotherapy for shorter periods. Cypress-specific IgG4 levels tended to increase in patients who had received cedar-pollen immunotherpy for longer periods, however, to a lesser degree than the cedar-specific IgG4 levels.
Thus, the allergen-speccific antibody titers demonstrated the ineffectiveness of cedar allergen immunotherapy against cypress pollen allergy in 2015, in which year, the average amounts of airborne pollen was lower than the average in the last 20 years, suggesting that cypress extracts should also be developed to treat cypress pollen allergy.
Salivary gland-type neoplasms arising in the nasopharynx are rare, accounting for less than 2% of all nasopharyngeal neoplasms. Herein, we report a case of mucoepidermoid carcinoma (MEC) of the nasopharynx, and along with a review of the literature, discuss the therapeutic strategies depending on the histological and radiological findings.
The patient was a 78-year-old man. He had first noticed a mass on the left side of the neck 9 months earlier, which began to gradually increase in size. Clinical examination revealed a tumorous lesion in the left nasopharynx. Both nasopharyngeal and cervical biopsies revealed the diagnosis of MEC, so that the patient was diagnosed as having nasopharyngeal MEC (T1N2M0, stage III). After induction chemotherapy with docetaxel plus cisplatin and fluorouracil (TPF), endoscopic removal of the tumor was undertaken via the endonasal approach, with bilateral neck dissection. Furthermore, postoperative chemoradiotherapy was also administered. Until now, two years six months since the completion of treatment, the patient has shown no evidence of local recurrence or distant metastasis. Based on our experience, it seems that our treatment approach is one of the valid treatment options for nasopharyngeal MEC.
Dermoid cysts on the floor of the mouth are reported to account for less than 2% of all dermoid cysts. These cysts of the floor of the mouth are classified by the Bergmann-Hagisaki classification into the sublingual type, submental type or sublingual-submental type based on their positional relationship with the oral structures. This classification is important for determining the appropriate surgical strategy. The cyst size and cyst position are also important considerations for selecting the appropriate surgical strategy. We encountered two cases of dermoid cysts of the floor of the mouth at our department, and present these cases here with some bibliographic consideration. The diagnosis in both cases was made by imaging and histopathology. The MRI findings were characteristic; we recognized a cyst with a clear margin and the sack-of-marbles appearance, visualized as low signal intensities on T1-weighted images, and as high intensites on T2-weighted images. The cyst in case 1 was diagnosed as being of the sublingual-submental type from the MR images. It was resected via the cervical approach. The cyst in case 2 was diagnosed as being of the sublingual type, and was safely resected via the transoral approach. If we can obtain a field of view taking into consideration the size and position of the cyst, we believe that it is possible to satisfactorily excise the cyst via approach from a single side.
Acute epiglottitis often causes rapidly progressive airway obstruction and death. Acute laryngitis other than epiglottitis can also sometimes cause airway obstruction and necessitate tracheostomy. Among patients who presented to our department from October 2009 to January 2017, 31 patients with acute epiglottitis required emergency tracheostomy. On the other hand, 5 patients with acute laryngitis other than epiglottitis, including 4 males and 1 female, also required emergency tracheostomy. These patients ranged in age from 56 to 68 years old. They presented to our hospital 3–6 days after developing sore throat, and endoscopic examination revealed laryngitis with airway obstruction, but no swelling of the epiglottis. Endoscopic examination is useful for making a decision on the need for tracheostomy. Laboratory data sometimes do not accurately reflect the severity of the airway obstruction.
We report a rare case of thyroid carcinoma metastasizing to the small intestine, causing intestinal obstruction and lower gastrointestinal bleeding. A 78-year-old woman who had undergone hemi-thyroidectomy and selective neck dissection for thyroid carcinoma presented to us with a history of vomiting and abdominal pain about 1 year after the surgery.
We conducted an emergency laparoscopic surgery for further investigation and control of the bleeding. Intraoperatively, a tumor lesion was observed in the ileum, and with the diagnosis of intestinal obstruction caused by a small bowel tumor, we performed partial small bowel resection. Histopathological examination of the resected specimen revealed that the tumor was a small intestinal metastasis from thyroid carcinoma.
Parathyroid carcinoma is a rare disease, accounting for 5% or less of all cases of primary hyperparathyroidism, and preoperative diagnosis is often difficult.
A 72-year-old woman was admitted to our department with primary hyperparathyroidism and a right cervical mass. She had sustained a fracture of her right radius a year ago and been diagnosed as having osteoporosis. Blood examination revealed elevated serum levels of calcium and intact-parathyroid hormone (PTH). Ultrasonography and CT of the neck revealed an irregular tumor measuring about 2 cm in diameter behind the right lobe of the thyroid gland.
The tumor was large with an irregular surface; therefore, malignancy was suspected, especially in view of the elevated intact PTH level.
At the time of resection of the tumor together with the surrounding adipose tissue, malignancy could not be excluded by rapid intraoperative frozen-section examination; therefore, partial resection of the right lobe of the thyroid gland and paratracheal lymph node dissection were also performed.
The tumor was diagnosed by postoperative histopathology as a parathyroid carcinoma. No evidence of thyroid invasion or lymph node metastasis was detected, and the serum intact PTH and serum calcium levels decreased after the surgery.
Needle aspiration cytology is not recommended for the diagnosis of parathyroid cancer, because of the risk of capsular damage and dissemination, and the diagnosis must be suspected from the clinical symptoms and imaging findings. In cases of parathyroid cancer, since cancerous tumors of the gland are larger in size than benign tumors, the tumors are easy to palpate, the intact-PTH and serum calcium levels are elevated and systemic symptoms tend to occur. If the tumor is small, homogeneous and has a smooth surface, a benign lesion would be suspected, whereas if the tumor is large and the aspect ratio is unequal, and there is evidence of lamellarization and/or metastasis, parathyroid cancer would be suspected. Adhesion of the tumor to the surrounding tissue during surgery is a finding that is suggestive of cancer. Treatment consists of extensive resection, and joint resection of the adherent tissues reduces the risk of recurrence, although about a half of the patients eventually develop local and cervical lymph node recurrence. Long-term follow-up is necessary for our case reported here.
Metastatic tumors involving the oral mucosa are rare, comprising 1 to 3% of all malignant oral neoplasms. Metastatic renal cell carcinoma invading the soft tissue of the oral cavity is extremely rare. Furthermore, metastatic renal cell carcinoma of the soft tissue of the oral cavity as the presenting feature is very rare. We report a case of metastatic renal cell carcinoma that initially presented to us with a tumor of the oropharynx. The patient was a 65-year-old man who visited our department complaining of discomfort in the throat. Fiberoptic endoscopic examination revealed a tumor on the dorsal aspect of the oropharyngeal soft palate. Tumor biopsy revealed no malignant findings. On the basis of the findings on contrast-enhanced computed tomography (CT), the tumor was suspected as a hemangioma and trans-oral tumor resection was performed. Postoperative histopathological examination revealed findings consistent with clear cell carcinoma. Further examinations revealed a tumor in the right kidney. Nephrectomy was performed and the tumor was diagnosed as a clear cell carcinoma. In patients presenting with oral tumors that do not show typical histopathological findings such as squamous cell carcinoma, whole-body examination is recommended considering the possibility of metastatic tumor.
One of the differential diagnoses of cervical lymphadenitis is tuberculous lymphadenitis, which can be difficult to confirm. Herein, we report a case of cervical tuberculous lymphadenitis, in which the diagnosis was made by polymerase chain reaction (PCR) assay and direct smear examination for acid-fast bacilli.
A 95-year-old female patient was referred to us with a cervical mass. She had undergone surgical incision and drainage for a left cervical abscess four months previously. One month later, she was referred for plastic surgery to treat a fistula that had developed at the site of incision. Three months thereafter, she was referred to us from the plastic surgery department for a right cervical mass with redness of the overlying skin. Ultrasonography revealed a mass with an irregular margin, poor blood flow, and heterogeneous contents on the right side of her neck. Cervical lymphadenitis was suspected and an antibiotic was prescribed. However, the size of the mass increased and an abscess evolved. The T-SPOT.TB blood test was positive, indicating the diagnosis of tuberculous lymphadenitis. We aspirated pus from the mass, and examination of direct smears of the pus and PCR revealed the causative organism as Mycobacterium tuberculosis.
Based on this experience, we recommend the use of PCR, direct smear examination, and interferon-γ release assays, such as T-SPOT.TB, for confirming the diagnosis of cervical tuberculous lymphadenitis.
We report a case of deep neck infection with extensive skin necrosis. A 60-year-old man fainted in his hotel room, and transported by ambulance to our hospital. He had disturbed consciousness and was diagnosed as having septic pre-shock. The skin of the anterior neck region showed extensive necrosis with smelly discharge. CT revealed numerous abscesses with gas production extending from the tonsillar region to the superficial and deep neck fascia. We carried out debridement of the necrotic areas and placed a drain. However, postoperatively, the skin necrosis extended to nearly half of the anterior neck region. Skin grafting was performed after 42 days. He discharged without any complications after 77 days.