Locally advanced squamous cell carcinoma of the head and neck (LA-SCCHN), which accounts for 60% of all cases of head and neck cancer, has a poor prognosis, despite multidisciplinary treatment. Induction chemotherapy (ICT) has been developed since the 1980s. The purposes of ICT are (1) improvement of the survival rate and prognosis through suppression of distant metastasis, and (2) function-preserving (larynx-preserving) through tumor shrinkage. The current standard regimen for ICT is docetaxel plus CDDP plus 5-FU (TPF therapy). However, it is not clear whether ICT followed by chemoradiation therapy (ICT-CRT) might be superior to CRT alone. There is controversy about whether ICT-CRT can be safely implemented, especially because of the high rate of treatment-related deaths following TPF treatment. Therefore, paclitaxel (PTX) plus carboplatin (CBDCA) plus cetuximab (Cmab) (PCE) therapy as IC for unresectable LA-SCCHN was investigated in a multicenter trial in Japan. This ICT protocol consisted of CBDCA at AUC=1.5, PTX at 80 mg/m2 and Cmab at an initial dose of 400 mg/m2, followed by 250 mg/m2, administered weekly for 8 weeks. Following this IC, CDDP (20 mg/m2, 4 days × 3 cycles, cumulative CDDP dose: 240 mg/body) and concurrent radiotherapy (70 Gy/35 fr/7 weeks) were started. The primary endpoint was the rate of CRT completion. The percent (%) CRT completion was 96.9%. The response rate was 88.6% to the ICT and 93.8% after the CRT phase. The 3-year overall survival rate was 83.5%. The main grade 3 toxicities were neutropenia (11.4%) and skin rash (5.7%) during the ICT, and oral mucositis (31.3%) and neutropenia (12.5%) during the CRT. In conclusion, the new ICT regimen of PCE shows promising efficacy and is a promising regimen.
Electric-acoustic stimulation (EAS), which enables hearing of high-frequency sounds via electrical stimulation and of low-frequency sounds via acoustic stimulation, is useful for patients with steeply or gradually sloping high-frequency hearing loss. Herein, we report a case of a 32-year-old female with CDH23 mutation who was treated by EAS in the left ear and cochlear implantation (CI) in the right ear. The patient presented with a steeply sloping high-frequency hearing loss, which responded poorly to hearing aids. However, one year after EAS surgery on the left side, her hearing threshold improved to 20-30 dB. While the word and sentence recognition scores in the speech recognition test (CI2004) performed preoperatively were 20% and 63%, respectively, at one-year after the treatment, both the scores improved to 100%. After the initial surgery, genetic testing revealed a mutation in the CDH23 gene. Therefore, owing to the expected decrease in residual hearing on account of the gene mutation CI was performed on the right side to improve the hearing further. It is important to be aware that predicting the risk of residual hearing loss by methods such as genetic testing, before surgery is useful for artificial hearing device selection.
We report a case of acute sinusitis with intracranial complications in a 15-year-old man who presented with fever, headache and swelling of the left eyelid. Computed tomography (CT) revealed opacities in the left maxillary, ethmoid, and frontal sinuses, and low-density convex opacities in the left frontal epidural region. Magnetic resonance imaging (MRI) revealed an iso-signal intensity on T1-weighted images and an iso- to high signal intensity on T2-weighted images in the left frontal epidural region. Enhanced MRI revealed enhancement of the dura, and we made the diagnosis of epidural abscess. Cerebrospinal fluid examination was performed, and the findings led to the diagnosis of bacterial meningitis. Staining of the cerebrospinal fluid revealed gram-positive cocci. We performed emergent trans-nasal endoscopic sinus surgery and started the patient on antibiotic therapy. The antibiotic therapy was continued for a total of about 3 weeks, and the patient improved without sequelae. Early diagnosis and treatment are very important, because intracranial complications of acute sinusitis may result in neurologic sequelae and could even be fatal.
Angioedema, a deep-seated edema that appears in localized areas of the skin and mucous membranes, could be classified as urticaria in a broad sense, but in contrast to normal urticaria, is not accompanied by erythema and pruritus. It occurs most commonly on the face, especially involving the lips and eyelids, and occasionally causes airway edema, which could cause suffocation.
We report a case of emergent surgical airway management for angioedema causing airway obstruction; the patient presented with angioedema more than 3 years after he had been initiated on treatment with an angiotensin-converting enzyme (ACE) inhibitor, one of the major classes of antihypertensive drugs. The patient presented to us with an acute attack of angioedema. The swelling of the lips and tongue was so intense that it was difficult to intubate, and we decided to perform surgical airway management. Thereafter, the swelling of the tongue and larynx decreased steadily by the day and the patient was discharged. However, even after discharge from the hospital, the patient presented with similar recurring episodes. Later, a neighborhood doctor implicated the ACE inhibitor intake as the potential cause.
Common features of ACE inhibitor-induced angioedema (ACEI-AE) are that they more often induce edema in the head and neck region as compared to other drugs, and that the interval from the start of intake of the drug to the appearance of symptoms varies from case to case.
Although varicella zoster virus (VZV) reactivation is well known to cause Ramsay Hunt syndrome, characterized by facial nerve paralysis and vestibulocochlear nerve disorder, it can also cause other cranial nerve disorders. Disorders of the vagus nerve are particularly common, and are usually unilateral, although there are also rare case reports of bilateral involvement. Herein, we report a case of bilateral vocal cord paralysis caused by VZV reactivation, along with a review of the relevant literature.
The patient was an 83-year-old woman who visited our department with the chief complaints of headache, pharyngodynia, and respiratory discomfort. Endoscopic examination of the laryngopharynx revealed redness, swelling, and mucosal eruptions in the left epiglottis and left arytenoid, in addition to saliva accumulation in the left pyriform sinus and bilateral vocal cord paralysis. Hematological examination revealed increased serum titers of VZV IgG and VZV IgM, and a cerebrospinal fluid examination revealed increased cell counts. Based on the findings, the patient was diagnosed as having with bilateral vocal cord paralysis and meningitis associated with VZV reactivation, and treatment was initiated with antiviral drugs and intravenous steroids. The patient was discharged from the hospital with improvement of the symptoms, on day 50 of the illness. The bilateral vocal cord paralysis resolved nearly completely within approximately three months of discharge.
Even in cases presenting with bilateral vocal cord paralysis, VZV reactivation should be suspected as a possible cause, and early therapeutic intervention may be necessary, especially in patients presenting with pharyngodynia and mucosal eruption.
Solitary fibrous tumor (SFT) is a soft tissue tumor that is rarely observed in the head or neck region. We report the case of a 43-year-old woman who presented with a 1-month history of a rapidly growing palate tumor and difficulty in eating. Tracheotomy was considered because of the possibility of airway obstruction by the tumor. Preoperative examination suggested bleeding risk during the operation, so that the procedure was performed with precautions taken to prevent bleeding. The patient was also considered to be at risk for perforation of the soft palate after tumor excision. Therefore, the soft palate was reconstructed with a mucoperiosteal flap prepared from the hard palate. Although histopathology indicated evidence of malignant transformation, the patient showed no evidence of recurrence or metastasis at the last follow-up conducted 1 year after the surgery. Long-term follow-up is necessary, so that any local recurrence or metastasis is detected and treated early.
Cancer of the external auditory canal is rare among head and neck cancers. Although the treatment of first choice is surgical resection, chemoradiotherapy is frequently selected for patients with advanced disease. Recently, proton therapy has been adopted for the treatment of cancers in the head and neck region, including in the external auditory canal, as it was shown to be almost as effective as radiotherapy, but with fewer adverse effects. Pseudoaneurysms have been reported as a fatal complication of radiation therapy or proton therapy for the nasopharynx and nasal cancer. Herein, we report the case of a 75-year-old male patient with cancer of the external auditory canal, who presented with recurrent episodes of bleeding due to ruptured pseudoaneurysms of the external carotid artery system, necessitating vascular interventional radiology and superficial temporal artery ligation several times after proton therapy. In patients receiving proton therapy, the possibility of complications such as necrosis, infection, and bleeding due to pseudoaneurysm formation and rupture should be borne in mind.
One of the major complications of a free flap transfer is thrombosis. We present a case in which free flap thrombosis was salvaged by intra-arterial injection of recombinant tissue plasminogen activator (rt-PA).
A 50-year-old man visited our hospital with the chief complaint of a progressively enlarging oral mass. We diagnosed the patient as having cancer of the hard palate, cT4aN2cM0, and performed radical surgery using a rectus abdominis myocutaneous flap. The flap became congested 27 hours after the operation, and we immediately decided to perform another operation. During the salvage surgery, we noted thrombosis in the flap at the site of the venous anastomosis and performed thrombectomy as thoroughly as possible. Because venous return from the flap remained weak even after thrombectomy, we suspected persistence of thrombosis within the flap. We tried injecting rt-PA into the flap artery in order to lyse the thrombosis. The venous return increased by 1 hour after this injection, and the color of the flap also improved. We completed the operation after anastomosing the veins. The color of the flap gradually turned positive (skin color) after the operation and the flap completely survived.
In conclusion, intra-arterial rt-PA injection may be safe and effective treatment for free flap thrombosis.
Warthin’s tumor is a benign, slow-growing tumor, found almost exclusively in the parotid gland. We report the case of a patient with a pseudo-malignant extra-parotid Warthin’s tumor with inflammatory changes. An 84-year-old woman was admitted to our hospital with a painless mass in the right breast. She was diagnosed by vacuum-assisted biopsy as having invasive carcinoma of the right breast. FDG-positron emission tomography (FDG-PET) was performed, which also showed a mass in the left supraclavicular fossa (SUVmax=33.2). The mass was suspected as a metastatic lymph node or a recurrent thyroid cancer, because she had been diagnosed as having papillary thyroid carcinoma and been treated by total thyroidectomy about 20 years earlier. Therefore, a left neck dissection was performed immediately. However, histological examination showed the typical findings of Warthin’s tumor with severe inflammation. There was no evidence of malignancy.
It is an accepted etiologic hypothesis that Warthin’s tumor originates from ectopic salivary gland tissue in lymph nodes. It is thought that extra-parotid Warthin’s tumors often develop in the neck lymph nodes. When encountering a neck tumor with inflammatory changes, Warthin’s tumor should be included in the differential diagnosis.
Pleomorphic adenomas are the most common type of all benign salivary gland tumors. Sometimes, they grow over long periods of time to reach giant sizes.
We report a case of giant pleomorphic adenoma of the right parotid gland. A 52-year-old man presented to us with a 6-year history of a gradually enlarging parotid gland tumor, which had begun to grow more rapidly during the previous year. Initial examination revealed a giant tumor of the right parotid gland without facial palsy. We suspected pleomorphic adenoma and removed the giant tumor. The tumor was 30×21×16 cm in size and the resected tumor weight was 6080 g. Histopathological examination revealed the diagnosis of pleomorphic adenoma, with no evidence of malignancy.
At 1 year 6 months after the surgery, a mass was observed in the right neck. CT revealed metastatic lesions in the cervical lymph node, lungs, rib, liver and kidney. The patient received chemotherapy (CBDCA+PTX), despite which tumor progression was observed. The patient died of respiratory failure due to lung metastases at 3 years after his first visit to our hospital.
In patients with pleomorphic adenoma, the possibility of malignant transformation, local recurrence, and distant metastasis should be borne in mind and patients should be followed up closely.
Background: Acute supraglottitis (AS) can cause airway obstruction, sometimes necessitating airway intervention. Some scope classifications were developed to predict the need for airway intervention in patients with AS, however, the most suitable classification for predicting the need for airway intervention remains unclear.
Objective: This study was performed to validate and compare the usefulness of three scope classifications (Katori’s, Tanaka’s, and Ovnat-Tamir’s classifications) for predicting the need for airway intervention in patients with AS.
Material and methods: We recruited 75 patients (44 males and 31 females aged 20–94 years) with AS who visited Kurashiki Central Hospital between January 2015 and September 2019. The areas under the receiver operating characteristic (ROC) curves (AUCs) of the scope classifications for predicting the need for airway intervention were measured.
Results: Of the 75 patients, airway intervention was needed in 23 patients. The AUC was 0.818 (95% confidence interval [CI] 0.715–0.922) for Katori’s classification, 0.803 (95% CI 0.699–0.907) for Tanaka’s classification, and 0.814 (95% CI 0.705–0.922) for Ovnat-Tamir’s classification.
Conclusions: Although all three classifications appeared to be useful, the AUC tended to be the highest for Katori’s classification.