Recurrence of cholesteatoma is mainly caused by poor mucosal regeneration in the middle ear cavity and mastoid cavity, often associated with changes such as granulation tissue formation, which can impair gaseous exchange in the middle ear cavity. If the middle ear mucosa can be preserved and rapid postoperative regeneration of the mucosa on the exposed surface of the bone can be achieved after middle ear surgery, the efficacy of surgical treatment for otitis media, including cholesteatoma, would potentially improve, and the physiological functions of the middle ear could be restored. Conventional canal wall-up tympanoplasty often results in a lack of mucosal regeneration in the resected area of the mastoid cavity, and changes such as granulation tissue formation often occur. In particular, it is extremely difficult to obtain mucosal regeneration in a poorly pneumatized mastoid cavity. To overcome these limitations, we developed a novel method combining canal wall-up tympanoplasty and autologous nasal mucosal epithelial cell sheet transplantation to promote postoperative regeneration of the middle ear mucosa.
We obtained the approval of the ethics committee of our institution and the Ministry of Health, Labour and Welfare for this clinical research. In our novel surgical technique, we endoscopically removed an approximately 10 ×10 mm area of nasal mucosal tissue from the inferior concha. Tissue-engineered autologous nasal mucosal epithelial cell sheets were fabricated by culturing the harvested cells using keratinocyte culture medium (KCM) containing autologous serum for 26 days in an aseptic environment in a good manufacturing practice (GMP)-compliant cell processing facility (CPF). The cultivated cell sheets were transplanted during canal wall-up tympanoplasty onto the exposed bony surface of the attic of the tympanic and mastoid cavities where the mucosa was lost.
We have performed this procedure on four patients with middle ear cholesteatoma and one patient with adhesive otitis media. All of the patients showed a favorable postoperative course, with no adverse events or complications.
Although CyberKnife is an effective treatment for local control of recurrent head and neck cancer, adverse events are not rare. Herein, we report the case of a patient with maxillary cancer who developed a brain abscess as a treatment complication 5 years after reirradiation with a CyberKnife.
A 55-year-old woman presented to our hospital with left maxillary pain, and was diagnosed as having left maxillary cancer, clinical stage T2N0M0. Concurrent chemoradiotherapy with nedaplatin and S-1 was administered, which resulted in complete remission. About 5 years later, however, the patient presented with a loco-regional recurrence and we performed partial maxillectomy, neck dissection and tracheotomy. Despite these treatments, however, the patient presented with a local recurrence again, and CyberKnife reirradiation was performed, which yielded complete remission. However, 5 years later, the patient presented with brain abscess as a late complication of CyberKnife reirradiation. Antibiotic treatment was started with the combination of meropenem and vancomycin, which failed to prevent progressive enlargement of the brain abscess. Stereotactic needle aspiration of the abscess under local anesthesia was performed by a neurosurgeon, and the patient recovered from the coma and right hemiparesis.
To minimize the risk of adverse events, it is important to studiously select candidates for reirradiation therapy and to coordinate closely with the radiotherapist.
Oropharyngeal hemorrhage can be caused by malignant tumors, occur post-tonsillectomy, etc. In some cases, it can prove fatal. However, it is rarely caused by acute infection. Herein, we report the case of a 61-year-old male patient with uncontrollable hemorrhage associated with lingual tonsillitis, which was eventually controlled by ligature of the external carotid artery (LECA).
The patient had undergone tonsillectomy about 20 years previously. He presented to us with marked swelling and furring of his lingual tonsil, based on which we made the diagnosis of lingual tonsillitis and initiated treatment with antibiotics and a steroid. Under our clinical observation, he recovered fairly well. However, 5 days after he was discharged, the patient returned to the hospital with abrupt and excessive bleeding from the oral cavity. We attempted, but failed to stop the bleeding, and the patient went into hypovolemic shock. We performed emergency tracheotomy followed by biopsy, and accomplished hemostasis by cauterization and LECA under general anesthesia. The bleeding stopped and blood transfutions were administered. Histopathological examination revealed only inflammatory tissue. The patient was discharged without any significant complications.
We assume that the tonsillitis exacerbated a chronic inflammatory state that the lingual tonsil was presumably in, resulting in necrosis of the surrounding tissues, including disruption of the integrity of the vascular walls.
The vessel involved here is highly likely to have been the dorsal tongue branch of the lingual artery.
We describe our experience of a case of intermuscular lipoma located in the perivertebral space.
The patient was a 48-year-old male who presented with the chief complaint of a right neck swelling, first noticed about two years earlier.
Cervical ultrasonography and MRI revealed a tumorous lesion expanding into the perivertebral space.
Intraoperatively, there were no adhesions between the lipoma and the surrounding tissue. Manual ablation of the lipoma was effective in the deep region, where the lipoma could not be visualized directly. We successfully accomplished complete resection of the lipoma without any serious complications.
In the management of intermuscular lipomas expanding into the perivertebral space, surgical treatment should be considered, because resection can be accomplished with little risk of postoperative complications.
Amyloid is an insoluble protein with a fibrous structure. Amiloidosis is the collective term used for diseases (syndrome) characterized by organ dysfunctions caused by amyloid deposition. Amyloidosis has been categorized mainly into systemic amyloidosis, in which amyloid deposition occurs in systemic organs, and localized amyloidosis, in which the deposition is limited to organ(s). Furthermore, it has also been categorized into various clinical types based on the type of amyloid protein (proprotein) deposited, including cervicofacial disease involving the tongue, lip, buccal mucosa, palate, jaw joint, and larynx. Amyloidosis is generally diagnosed on the basis of symptoms arising from amyloid deposition in the kidney, heart or gastrointestinal tract. However, herein, we report a case encountered by us, wherein the diagnosis was made in a patient who presented with a submandibular swelling.
It is rare for amyloid deposition in the tongue and submandibular swelling caused by amyloid deposition to exert any influence on the prognosis in cases of amyloidosis. However, considering the possibility of narrowing of the airways and the possibility of systemic amyloidosis, histopathological examination and examinations to exclude heart disease, gastrointestinal disease and renal disease should be performed and treatment should be promptly initiated.
We report a case of posterior reversible encephalopathy syndrome (PRES) caused by 5-FU plus cisplatin therapy.
A 56-year-old man visited another hospital with the complaint of left cheek pain. He was diagnosed as having locally advanced maxillary sinus squamous cell carcinoma and started on superselective intra-arterial infusion of cisplatin and concomitant radiotherapy. During the follow-up period, he was diagnosed as having recurrent maxillary cancer, and initiated on chemotherapy with 5-FU plus cisplatin. On day 26 of chemotherapy, he manifested disturbance of orientation and abnormal behavior. Magnetic resonance imaging (MRI) of the brain was performed, which revealed abnormal hyperintensities in the occipital-parietal lobes bilaterally in the T2-weighted images. Based on the typical findings on brain MRI, the patient was diagnosed as having PRES, which is known to be caused by chemotherapeutic drugs. He was started on treatment, with antihypertensive and anticonvulsant drugs. By two weeks after the start of treatment, his symptoms, as well as entirely the bilateral posterior lesions on MRI, entirely disappeared.
Physicians should be alert to the possibility of adverse reactions to chemotherapeutic drugs involving the central nervous system, such as PRES.
We present a case report of a 69-year-old man who developed delayed hypopharyngeal perforation, because of instrumentation failure, 9 years after anterior cervical spine fixation with plating. The patient presented with the complaints of odynophagia and dysphagia. The injury was caused by dislodgement of the cervical plate. We removed the plate and screw, and sutured the hypopharyngeal wall defect. At present, 10 months after operation, the patient remains asymptomatic.
Anterior cervical spine fixation with plating is a well-established surgical treatment method. Common indications are cervical degenerative disc disease, neoplasms, and trauma. Use of plates has resulted in early spine stability, early patient mobilization, improved union rate and reduced hospital stay. However, several complications has also been reported. Hypopharyngeal perforation is uncommon, but is a potentially highly morbid or even fatal complication. In most cases, the diagnosis is made early, while in some cases, the diagnosis is delayed by years. Management of hypopharyngeal perforation caused by penetrating osteosynthesis material depends on the patient’s general condition, stability of the spine, and the morphological features of the perforation. Early diagnosis and appropriate individualized treatment are essential.
Leiomyoma of trachea is one of the rarely encountered benign tumors, accounting for about 4% of all benign tracheal tumors. A 69-year-old woman with Diffuse Large B-cell lymphoma (DLBCL) was found on PET to show tracer accumulation in the trachea. She had no symptoms, and we identified the tumor in her trachea by fiberoptic laryngoscopic examination. We performed tracheotomy and tumorectomy under local anesthesia. Histopathological examination of the resected tumor revealed spindle-shaped tumor cells with mild nuclear atypia, proliferating in an interlacing pattern in the subepithelial layer, and a few mitotic figures in the nuclei; immunostaining revealed positive staining results for α-SMA and desmin. Until now, 8 months since the surgery, she has shown no signs of tumor recurrence. We had exenterated the tracheal leiomyoma safely and she is now living leiomyoma-free.
A 45-year-old man was admitted to our hospital with a few days’ history of persistent sore throat and fever. His white blood cell count was 15800/mm3 (differential neutrophil count 82.5%). The serum C-reactive protein level was elevated to 20.55 mg/dL. From these findings, we made a provisional diagnosis of bacterial infection. However, treatment with antibiotics failed to yield improvement of the symptoms. Histological examination revealed an infiltrate consisting of mononuclear cells and numerous neutrophils in the abdominal dermis. Based on the findings, we made the diagnosis of Sweet’s syndrome. Prednisolone was highly effective, the patient showing a dramatic response, with complete resolution of the fever within a day and of the skin lesions within two weeks. Sweet’s syndrome is the most representative entity of the febrile neutrophilic dermatoses. Patients typically present with pyrexia, neutrophilia, and painful tender erythematous papules and nodules often distributed asymmetrically. Affected sites show a characteristic neutrophilic infiltrate in the upper dermis. Antibiotics are ineffective for the treatment of Sweet’s syndrome, but systemic corticosteroids are highly effective and should be the first-line of treatment. High fever, neutrophilia, and elevated serum C-reactive protein are most suggestive of bacterial infection, but Sweet’s syndrome should be borne in mind in the differential diagnosis.
In 1989, Sinave et al. described the following criteria for the diagnosis of Lemierre’s syndrome (LS): 1) primary infection of the oropharynx; 2) septicemia demonstrated by at least one positive blood culture; 3) evidence of thrombophlebitis of the internal jugular vein (IJV); 4) metastatic infections at one or more distant sites. In 2007, Riordan reported that the use of IJV thrombophlebitis as an essential criterion excluded a high proportion of otherwise typical cases. He proposed the following criteria: 1) history of anginal illness in the preceding 4 weeks or compatible clinical findings; 2) evidence of metastatic lesions in the lungs and/or at another remote site(s); 3) evidence of IJV thrombophlebitis or isolation of Fusobacterium necrophorum or Fusobacterium sp. from blood cultures or a normally sterile site. However, both Sinave’s and Riordan’s definitions would fail to diagnose patients with primary infection at sites other than the oropharynx. We identified 62 published cases of LS in Igaku-chuo-zasshi. Only 14 of these cases (22%) fulfilled all of Sinave’s criteria and only 34 (55%) fulfilled all of Riordan’s criteria. Many cases that were (i) culture-negative, (ii) in whom other bacterial strains than Fusobacterium were isolated, and/or (iii) in whom the primary infection involved a site other than the oropharynx were also diagnosed as LS. Rapid diagnosis of LS is essential, as a delay in the diagnosis could be fatal. Based on the above, we propose the following modified criteria for the diagnosis of Lemierre’s syndrome: 1) primary infection of the head and neck region; 2) evidence of metastatic lesions in the lungs and/or at another remote site(s); 3) evidence of IJV thrombophlebitis or septicemia demonstrated by at least one positive blood culture. In deep neck infections such as neck abscesses, IJV thrombophlebitis becomes an important criterion for the diagnosis of the LS. Deep neck infections with thoracic empyema via a mediastinal abscess should be excluded, however, because this dose not fulfill the criterion of “remote lesion.” Of the aforementioned 62 published cases, 53 (85%) fulfilled all of the above modified criteria.
Yoko Yamamoto and Makoto Sugiura contributed equally as the first authors.