Some issues concerning head and neck surgery, such as reconstruction after tumor resection, prevention of postoperative complications, swallowing function and voice rehabilitation after surgery, have been debated in recent years. However, borderless and seamless collaboration between head and neck surgeons and plastic surgeons has still not been completed. An invisible border may remain between us.
We presented movies that explained how we cooperate in the management of patients with head and neck cancer. Our institute has some positive features in the management of patients. One of them is “We're a team of head and neck surgeons and a plastic surgeon”. Another is “Not only head and neck surgeons but also a plastic surgeon and radio-oncologists join the routine meetings on all cases before treatment”. The former system was set up in 1985 and the latter in 1995. Head and neck surgeons and the plastic surgeon now collaborate in the outpatient ward as well. We believe that such cooperative treatment for patients maintains the quality of management and helps improve their QOL throughout the treatment and outpatient follow-up.

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Head and neck cancer surgery, consisting of primary resection, neck dissection and reconstruction, is a collaboration of surgeons who resect cancer (ENT surgeons, oral and maxillofacial surgeons) and plastic surgeons. Paying attention to postoperative function is necessary; however, radicality of surgery is the primary concern. With elective neck dissection of N0 patients, vessel preservation is a matter of course, and is not impossible in treatment by neck dissection. Preserving cervical vessels in good condition for microanastomosis enables plastic surgeons to reconstruct a surgical defect using a free flap easily and freely. This reduces operating time and postoperative complication rate, thus improving the quality of life of head and neck cancer patients after major surgery.

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One of the most important purposes of reconstructive surgery for patients with advanced hypopharyngeal cancer is to reconstruct the upper digestive tract. On the other hand, postoperative complications such as orocutaneous fistula or surgical site infection can easily develop, and these complications can cause a delay of adjuvant therapy or postoperative rehabilitation, thus decreasing the patients' quality of life. So, the next important purpose in head and neck reconstruction is to reduce postoperative complications.
There are several keys to successful functional reconstruction and measures to avoid postoperative complications. One of the most important keys is to reduce surgical intervention through a team approach and standardization of surgical procedure. In this report, we describe our surgical cooperation system between head and neck surgeon and reconstructive surgeon, and outline our standardized reconstructive procedures.

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The standard treatment for patients with head and neck cancer is thought to be concurrent chemoradiotherapy (CCRT). Since the 1980's, several clinical trials have been performad to evaluate the ability of larynx preservation using CCRT. However, functional deficit such as dysphagia and aspiration due to toxicity of CCRT is a significant problem in cases requiring larynx preservation. Induction therapy using multi-agent chemotherapy including docetaxel proved to be advantageous and several clinical trials are under way to compare with CCRT. Hyperfractionated or accerelated radiotherapy (altered fractionated radiotherapy) has been shown to be of clinical benefit, and modified fractionated radiotherapy combined with concurrent chemotherapy has been shown to improve the clinical outcome. Molecular targeting agents are believed to have a promising effect in addition to radiotherapy and/or CCRT, and several trials are now testing their efficacy.

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Objective: Concurrent chemoradiotherapy (CCRT) is one of the recent emerging modalities for advanced squamous cell carcinoma of the head and neck (SCCHN), because of its good efficacy and functional preservation. However, some of the patients treated by CCRT have residual or recurrent tumors in primary sites and/or cervical lymph nodes. In these cases, salvage surgery is considered to be useful for locoregional control and disease-free survival. This study analyzes the usefulness of salvage surgery after CCRT for SCCHN.
Method: The medical records of 111 consecutive patients (stage II: 17%, stage III: 6%, stage IV: 77%) treated with CCRT for SCCHN (hypopharynx: 49, oropharynx: 28, larynx: 17, nasopharynx: 10, others: 7) from 2003 through 2008 were reviewed.
Results: Fifteen patients underwent 22 surgical procedures. The types of procedures performed were as follows: selective neck dissection: 15, total pharyngolaryngectomy: 3, total laryngectomy: 3, oropharyngeal tumor resection: 1. All the 15 patients with salvage surgery had good locoregional control except two cases. Major wound complications (pharyngocutaneous fistula and necrosis of rectus abdominis myocutaneous free flap) occurred in 2 of 15 patients and were successfully managed by re-operations. There were few other minor complications such as wound infection and laryngeal edema.
Conclusion: Salvage surgery can be safely performed and is considered to be useful for locoregional control after intensive CCRT.

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The anatomy of the skull base and central part of the head is very complicated since it consists of both bone and soft tissue, and also includes important organs. These areas are situated deep in the center of the skull, therefore, tumors in these areas are difficult to manage. An adequate surgical approach, based upon thorough estimation of these lesions, is key for the surgery. Surgical support systems are also important.
Based on an imaging study, we individually made surgical managements for skin and bone. We drew up the best surgical plan for the patients, considering adequate management of both skin and bone. To establish this combined surgical approach, the use of endoscopes and navigation systems as well as multidisciplinary care are important.

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At our Center, desquamation/enucleation is performed using a cervical approach as a basic procedure for primary parapharyngeal neoplastic lesions. However, operation on a tumor on the basilar side must inevitably be performed blindly, and if the affected region involves middle basilar bone, or is a wide-ranging lesion toward the infratemporal fossa, there is a very limited visual field for sparing the facial nerve during operation. In such cases we develop resection sparing the facial nerve, zygomatic arch and mandible without facial skin incision by adding an approach from the anterolateral retromaxillary pathway via the gingivobuccal sulcus or subtemporal approach. The dead space resulting from enucleation of the tumor will be selected and filled by free-flap or most appropriately selected local for each case. The surgical technique is described herein. This procedure is mainly for benign tumors but is also effective for low-grade tumors.

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In cases of long-standing facial paralysis, neurovascular free muscle transfer is generally accepted as the ideal way to obtain good results in patients with facial paralysis. However, another method should be required in older patients or patients with a poor prognosis. In cases with abrasion of a malignant tumor and a facial nerve, facial suspension operations are one of the effective procedures. The muscle bow traction method was developed for dynamic facial reanimation and facial suspension utilizing the masseter muscle and a fascia sling. The principle of this method is that the sling around the muscle pulls the oral commissure laterally and backward by the restitutive force of the muscle from its relaxed position to its contracted position. This method combined with other static procedures was applied to 14 patients with long-standing facial palsy and immediately applied to 14 patients with a malignant tumor and facial nerve abrasion in the head and neck regions. All the patients with long-standing paralysis evaluated improved based on House-Brackmann grading. The restored motion of the oral commissure ranged from 3 mm to 10 mm when clenching the jaws in all the patients. The advantage of this method is that it is less invasive to the muscle and is a simpler procedure than other conventional muscle transposition methods. We believe that the muscle bow traction method is an effective alternative for older patients and patients with advanced cancer and it is an effective procedure for immediate reconstruction at the time of tumor and facial nerve abrasion, too.

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In the treatment of established facial paralysis, reconstruction for total facial reanimation requires several kinds of operative procedures. Main targets for reconstruction are the eyebrows, eyes, cheeks, and lower lips. For the eyebrows, direct skin excision above the paralyzed eyebrow, which is mainly indicated in the elderly patients, is the most reliable method, although an endoscopic eyebrow lift should be used in young patients. Lid loading is good for patients with a slight lagophthalmos. However, contour of the plate is conspicuous in some patients and the technique cannot be used for patients who are allergic to gold. Conversely, temporary muscle transfer should be employed for complete eye closure. The Kuhnt-Szymanowski method should be employed as an ancillary approach for patients with severe ectropion. For the cheeks, face lift is a good procedure for incomplete paralysis. However, patients with slight or no movement of the cheek when smiling need a neurovascular free muscle transfer. For the lower lips, selective neurectomy or myectomy should be employed for symmetry of the lower lip. Neurovascular free muscle transfer is recently employed for dynamic reconstruction. With these operative techniques, symptoms of established facial paralysis should be treated comprehensively.

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In this paper we describe our therapeutic strategy for established facial palsy and indications for the operative procedures, and evaluate and compare the outcome of the several operative methods which we have performed in each facial region such as the eyebrows, eye lids and around the mouth.
We also present a computer-based three-dimensional objective method for analyzing facial movement from video recorded images, which we developed for the quantitative assessment of facial nerve palsy, and demonstrate the clinical usefulness of the system. The system calculates the optical flow (motion vector) of each pixel on the recorded image and enables detailed and regional evaluation of facial movement. The system is useful particularly for the post operative assessment of dynamic reconstruction such as facial reanimation with free muscle transfer.

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For reanimation of the mouth commissure in patients with established facial paralysis, we use a reconstructive algorithm according to goal of smile reconstruction, risks and requests of the patients. The first choice of options in our institution is one-stage reconstruction using neurovascularized muscle flap. We prefer to use the short head of the biceps femoris muscle, as well as the latissimus dorsi and the rectus abdominis muscles. For patients who are not good candidates for microvascular anastomosis, regional muscle transposition is selected for facial reanimation. Our current preferred method is lengthening temporalis myoplasty. The entire muscle based on the deep temporal neurovascular bundle is elevated and transferred to the oral commissure through a tunnel beneath the zygomatic arch. The advantages of lengthening temporalis myoplasty are that effective movement of the oral commissure can be achieved within several weeks after the operation, and no deformities remain in the donor site. Although the innervation of the transferred muscle depends on other nerves rather than the facial nerve and needs physical therapy, symmetrical movement of the transferred muscle can be expected via the cross-face nerve graft. When patients are not good candidates for microvascular anastomosis or regional muscle transfer, we choose the muscle bow traction method which is as follow. A strip of tensor fascia lata approximately 15 cm in length is harvested, and then passed around the anterior half of the masseter. The commissure moves by restoring force of the muscle when it contracts. The advantage of this method is that it is less invasive to the muscle and is a simpler procedure than other conventional muscle transposition methods. For lower lip palsy, a simple method using fascia graft is adopted to restore the individual pattern of smile.

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In the field of head and neck surgery it is often necessary to make incisions to the face, which is exposed, thus requiring the surgeon to take aesthetics into consideration and to minimize visible scarring. In principle, skin incisions should be along wrinkle lines, the hair line, or the borders of the nose, auricle, lips, etc. Skin suturing should be performed using both dermal sutures, in order to reduce tension in the wound margin, and fine epidermal sutures, so that suture marks do not remain. The aim from incision through suturing should be that all procedures are always atraumatic to the skin. After stitch removal, skin tapes should be used in order to maintain a fine, flat, concealed linear scar and shield from UV light and it is important to be vigilant with regard to care and follow-up for changes in scars.

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Issues concerning care for patients with head and neck cancer are described. Despite their relative long survival, the patients have many problems such as changes in facial configuration after surgical operations, communication problems due to loss of voice and the need for a change of route for administering analgesics due to dysphagia. The patients may have various pains such as tumor-related pain and cancer therapy-related pain. The pain can be classified into three categories, i.e. nociceptive pain, neuropathic pain and mixed neuropathic pain. Nociceptive pain can usually be treated by opioids, but neuropathic pain is often refractory to opioids. Adjuvant analgesics such as anticonvulsants and antidepressants are the main treatment for neuropathic pain. The pain of patients with head and neck cancer is often affected by psychological factors as mentioned above. In caring for these patients, palliative care specialists need to know the characteristics of patients with head and neck cancer.

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Recently, to minimize donor site morvibity, free perforator flaps such as radial artery perforator (RAP) flap, thoracodorsal artery perforator (TAP) flap, deep inferior epigastric artery perforator (DIEP) flap, deep and superficial circumflex iliac artery perforator (SCIP, DCIP) flaps, anterolateral thigh (ALT) flap, TFL perforator flap, and gluteal artery perforator (GAP) flap have become widely used. In addition, with the introduction of the new technique of super-microsurgery, dissection and anastomosis of small vessels and fascicles of less than 0.8 mm in diameter has bcome possible. With this technique, small vascularized tissue including adiposal tissue, nerve fascicles, periosteum, septal fascias, partial auricle, and foot web space flap have been recently used to repair facial deformities, nerve gaps, trachea, total eyelids, and oral commissure, etc.

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Between April 1997 and August 2007, 295 patients with locally advanced, histologically proven, and new or recurrent cancer of the head and neck were treated with carbon ions. Treatment dose was 64.0 GyE/16 fractions/4 weeks (or 57.6 GyE/16 fractions/4 weeks when an extensive area of skin was included in the target volume).
There were no early reactions worse than grade 3 and no late toxicities worse than grade 2. The effectiveness for the tumor at six months was CR for 34 patients, PR for 136 patients, NC for 121 patients and PD for 5 patients, with the effective rate being 57%. The five-year local control rate, by histological type, was 81% for the 38 adenocarcinoma patients, 81% for the 13 papillary adenocarcinoma patients, 71% for the 90 adenoid cystic carcinoma patients, 75% for the 95 malignant melanoma patients and 56% for the 15 squamous cell carcinoma patients. The five-year survival rate was 71% for adenoid cystic carcinoma, 56% for adenocarcinoma and 36% for malignant melanoma.
Carbon ion radiotherapy for head and neck cancer can be considered to present no clinical problems. The therapeutic effectiveness was particularly outstanding for non-squamous cell carcinoma, a tumor intractable to photon radiotherapy.
On the basis of the analysis results, part of this study was divided into two additional protocols for bone and soft tissue sarcomas and mucosal malignant melanomas.

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It is well known that head and neck surgery involving reconstructive procedures takes a long time. In spite of the long time that such surgery requires, the fee for such operations is low under the Japanese health care system.
An examination was made to determine whether the fee was suitable or not, based on Miyagi Cancer Center's data.
According to the Japanese Fee Schedule (“Tensu-hyo”), there are some differences in the hourly rate of the operation fee among surgical departments. For example, as compared to the fee of thoracic surgery, the operation fee was found to be nearly three times higher than that for head and neck surgery for hour. Another problem with the fee structure for such procedures is as follows.
In cases where resection and reconstruction are performed simultaneously, the reconstructive procedure is determined based on the main operation while the operation fee for the other procedure becomes half price. This is unreasonable because each surgical field is quite different. Both fees should be set up equally.
Another problem is the case of neck dissection following primary lesion resection. In these cases, the fee for neck dissection is extremely low because there are additional procedures involved.
As mentioned above, there are many problems concerning the adequacy of the operation fee for head and neck surgery under the Japanese health care system. The author emphasizes that a suitable correction of the head and neck surgical fee is required.

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Compensation for medical examinations and treatment is a major social problem and closely linked to the economic financial status of countries. Compensation for work is restrained by the social security budget. We cannot expect total medical costs to increase in future if this policy is not changed. 10% of the national general practice medical care cost is for cancer examination and treatment charges, and 10% of it is for surgical operation charges.
The annual total compensation for radical head and neck cancer operations is 2.4% (about 8 billion yen) of the total for cancer operations.
We should demand a large increase in future. Radiation therapy charges are increasing smoothly due to continuous actions fully supported by the Japanese Society for Therapeutic Radiology and Oncology (JASTRO).

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Intra-arterial chemotherapy for head and neck squamous cell carcinoma is widely conducted across Japan. Interventional radiology, by making full use of catheterization techniques, plays an important role in this treatment, and various inventions ranging from catheters to imaging modalities and injection device have been added. In the present paper the basic concepts and technical inventions in intra-arterial chemoinfusion therapy of head and neck cancers, together with some major complications, are described. Special emphasis is placed on the arterial channel alteration technique, because this procedure is considered to greatly enhance the chemoinfusion therapy. Also, some major problems to be solved in this treatment are presented.

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A joint study of chemoradiotherapy using superselective intra-arterial infusion via superficial temporal artery was undertaken to consider a standard therapy for tongue cancer. Six reports of chemoradiotherapy using this method were analyzed for the treatment schedule of the joint study. The treatment schedule was determined to be the administration dose of CDDP of 30∼50mg/m²/week (total: 180∼300mg/m²). Radiotherapy (2Gy/day) was given 5 days a week during 6 weeks.

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To establish the clinical usefulness of arterial injection therapy in the treatment of head and neck cancer and other cancers, it must meet the following 4 conditions: 1) The treatment procedure is stable, with a high reproducibility and safety; 2) The extent of arterial injection that covers the entire tumor can be confirmed; 3) Anticancer agents appropriate for arterial injection therapy are selected, and an optimal dose is established; and 4) Arterial injection therapy is more advantageous than other treatments such as radiotherapy alone, chemoradiation therapy involving systemic chemotherapy and radiotherapy, and surgery.
Initially, concerning the stability of the treatment procedure, selective arterial injection has been performed since we employed the procedure in November 1999, and the procedure has been stable without any drop-out cases.
Concerning the second condition, the extent of arterial injection has been confirmed by the MRI flow-check method (MFCM) . Concerning the third condition, the results of arterial injection therapy with CDDP were significantly better than those of continuous arterial injection therapy with CBDCA.
Concerning the last condition, arterial injection therapy for advanced oral cavity cancer may be potentially more useful than other therapies.

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In this article, we report our function preservation surgeries for T2 and T3 laryngeal cancer, supracricoid laryngectomy with cricohyoidoepiglottopexy for glottic cancer and transoral resection for supraglottic cancer.
Supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP), which is mainly indicated for unfavorable T2 and T3 glottic cancer, provides radical resection and laryngeal preservation without permanent tracheostomy. We performed this surgery for 27 cases, of which 11 cases were performed as a primary treatment. Laryngeal preservation and cause specific survival rates were 100% and 100% (observation period: 5-27 months, average: 45.7 months). Functional results were also satisfactory by PSS-HNC. CHEP is considered to be useful as a laryngeal function preserving treatment for locally advanced glottic cancer.
We performed transoral partial laryngopharyngectomy for T2 and T3 supraglottic cancer using our newly designed endoscopic surgical system. This procedure without tracheostomy and neck skin incision could be performed less invasively. Oncological outcome and postoperative laryngeal function were excellent. Transoral partial laryngopharyngectomy could be a new treatment of choice for supraglottic cancer.

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The strategies in the treatment of T2/T3 laryngeal cancer were investigated retrospectively from the viewpoint of larynx-preservation surgery. A total of 229 patients with T2/T3 laryngeal cancer were treated between 1996 and 2005, in which period all strategies in the treatment of head and neck cancers were decided at a weekly conference consisting of head and neck surgeons and therapeutic radiologists. The distribution of T-stage was as follows: 79, 38 in T2, T3 glottic carcinoma, and 50, 67 in T2, T3 supraglottic carcinoma, respectively.
The rate of larynx preservation in T2 glottic carcinoma was 84% (66/79), although the local control rate of radiation therapy in this group was 68% (49/72). Similarly the larynx-preservation rate in T2 supraglottic carcinoma was 80% (40/50), although the local control rate of the therapy was 67% (28/42). More than half of these patients with recurrent primary lesion after radiation therapy were treated by larynx-preservation surgery as salvage, which improved the rate of larynx preservation. On the other hand, the local control rates of larynx-preservation surgery, which included T3 carcinomas, were 95% (20/21) in glottic carcinoma and 94% (15/16) in supraglottic carcinoma, respectively.
When considering the larynx-preservation strategies in the treatment of T2/T3 laryngeal cancer, it is worth noting the following point: chemoradiation therapy is surer than larynx-preservation surgery in respect of the anticipated functional outcome after treatment, but larynx-preservation surgery is more certain than radiation therapy as regards the local control rate. Case for surgery should be selected accordingly.

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Most cases of T2N0 glottic cancer are treated with conventional radiation therapy in Japan. However, the local control rate of conventional radiation therapy for T2N0 glottic cancer is reported to be 60∼70%. To improve curability, surgery is performed in some cases, although total laryngectomy results in lost voice. Recently, supracricoid laryngectomy with cricohyoidoepiglotto-pexy (CHEP) has been introduced to practical medicine for T2N0 glottic cancer in Japan. However, even using CHEP, surgery is much more invasive than radiation therapy or chemoradiation therapy in terms of voice function. Therefore, our team uses concurrent chemoradiotherapy using TS-1 for favorable T2N0 glottic cancer and uses concurrent chemoradiation using TS-1 or CHEP for unfavorable T2N0 glottic cancer at the request of patients. The 3-year overall survival rate and 3-year local control rate of concurrent chemoradiotherapy using TS-1 for T2N0 glottic cancer are both 100% at Kitasato University Hospital.

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The fundamental goals of parotid pleomorphic adenoma surgery are: 1) prevention of recurrence, 2) preservation of the facial nerve, 3) prevention of postoperative Frey's syndrome, 4) prevention of salivary fistulas, and 5) preservation of salivary gland function. The cause of recurrence is most probably an inadequate excision, such as enucleation. The tumor capsule is closely related with the recurrence of pleomorphic adenoma. Furthermore, another cause of recurrence can be to have to preserve the facial nerve. Most recurrence cases tend to suffer multiple and repeated recurrences, and the danger of a malignant change rises.
In fact, carcinoma ex pleomorphic adenoma is highly malignant in many cases (high grade adenocarcinoma, salivary duct carcinoma, etc.). Therefore, it is important to select an appropriate first-time operation so that it may not recur.

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Malignant tumors of the parotid gland are classified into various histological types. Their diagnosis and treatment, and prognosis including QOL are affected by histological variations and management of facial nerves.
During the 10-year period from 1997 to 2006, 54 cases were treated at Aichi Cancer Center. According to histological grade, the 5 and 10-year disease-specific survival of resected 49 cases were 86% and 79% for low and intermediate grade, and 48% and 31% for high grade, respectively. Prognostic factors were evaluated using Cox proportional hazard models. T and N of UICC TNM classifications and histological grades were significant prognostic factors.
Immediate facial nerve reconstruction is very demanding after a total parotidectomy. Under such conditions, we reconstructed facial nerves using vascularized sural nerves with free lateral gastrocnemius muscle flap.
We evaluated the clinicopathological features of mucoepidermoid carcinoma translocated gene 1-mastermind-like gene family gene fusion, and this gene transcript may be specific to mucoepidermoid carcinoma and associated with a distinct clinicopathological mucaepidermoid carcinoma subset that exhibits an indolent clinical course.
In order to improve the prognosis and QOL, new approaches such as molecular biology, corpuscular radiotherapy and targeted therapy should be evaluated under a multi-institutional trial due to low incidence and histological variety of malignant tumors of the parotid gland.

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Purpose: We report the usefulness of MR imaging in distinguishing the differential diagnosis of parotid gland tumors. Materials and Methods: We studied MR images of 95 patients with 97 tumors (63 benign tumors and 34 malignant tumors). T2-weighted images (WIs), T1WIs, contrast-enhanced T1WIs, diffusion weighted single-shot EPI images (DWIs), and dynamic-enhanced images were acquired with a 1.5-Tesla MR system and a head-neck 8-channel coil. All tumors were classified into 5 groups, which were pleomorphic adenoma (PA), Warthin's tumor, other benign tumors, carcinoma, and malignant lymphoma. Results: Benign tumors were oval or lobulated shapes with complete encapsulation. Malignant tumors were irregular shapes without encapsulation. PAs had high apparent diffusion coefficient (ADC) values higher than 2.0mm²/sec. Warthin's tumors had a characteristic time intensity curve with rapid increase and rapid decrease. Conclusions: Our data suggest that MR characteristics are helpful in the differential diagnosis of parotid gland tumors.

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Parotid gland tumors are unique in their histomorphological variability, which may present considerable diagnostic challenges to the pathologist. The classification of these lesions is complex, encompassing more than 30 named epithelial tumors, but the various types of parotid gland tumors are distinct in their clinical behavior and response to treatment, and the surgical pathology diagnosis weighs heavily on therapeutic decisions and patient prognosis. At present, the second edition of the WHO histological classification of salivary gland tumors published in 1991 seems to be internationally accepted and used. The new WHO classification of salivary gland tumors was included as one of the chapters of the Blue Book on the Pathology and Genetics of Head and Neck Tumours published in 2005 by IARC Press. This edition was based on data of newly described tumor entities as well as histological variants and the behavior and prognosis of the previously classified tumors. At this time, some uncommon tumor types, such as non-sebaceous type of lymphadenoma, clear cell carcinoma NOS, and sialoblastoma, have been newly listed as separate entities, and several histologic variants and extremely rare tumors have been included in the classification. In addition, the terminology of some tumor entities has been changed. This review article attempts to summarize the WHO histological classification of salivary gland tumors focusing on the changes made between the first, second, and 2005 editions. Furthermore, a practical approach to the pathological diagnosis of parotid gland tumors will also be discussed briefly.

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Appropriate training and treatment based on evaluation are important for patients with dysphagia after head and neck surgery, and improvement of efficiency will bring better results. However, many of the rehabilitation techniques that have been developed focused on patients with dysphagia caused by stroke.
Roughly speaking, the standardized evaluation includes a screening test and diagnosis of dysphagia. The repetitive saliva swallowing test is widely used for screening of aspiration, and the cough test for silent aspiration. From our investigation, the results of screening tests were partially different between head and neck patients and other patints. Videofluorography and videoendoscopy are useful for diagnosis.
Moreover, we need to know how head and neck surgery affect the pharyngeal stage of swallowing when giving appropriate training to patients. Our study showed that head and neck surgery caused some characteristic changes in pharyngeal swallowing.
The clinical pathway made our rehabilitation system more efficient. The team approach depending on each hospital or environment leads to successful dysphagia rehabilitation.

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Chewing and swallowing dysfunctions after surgical treatment adversely impact the quality of life of patients with oral and oropharyngeal cancers. To address this issue, for the past six years, we have been working to develop an effective rehabilitation program in which speech therapists play a central role. To better understand the surgical procedures in detail and background information of the patients, speech therapists attend the preoperative meeting and sit with head and neck surgeons at the time of informed consent. The speech therapists then start their clinical care as preoperative orientation. In this article, we report our experience of the team approach and describe our rehabilitation program for chewing and swallowing in concrete.

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The terminology for vascular anomalies of the head and neck is confusing, and they are often called “hemangioma.” Differential diagnosis is important in order to apply the proper management for each lesion. According to the classification by the International Society for the Study of Vascular Anomalies, they are classified into vascular tumors and vascular malformations based on the endothelial behavior. Infantile hemangioma is the most common benign tumor caused by rapid postnatal endothelial proliferation, and typically involutes by ten years of age. Pharmacological therapy is required for serious lesions along the airway or the orbit with function-threatening symptoms. There is a rare congenital form of hemangioma, which is fully developed at birth and either rapidly involutes within the first year of life (rapid-involuting congenital hemangioma, RICH) or persists for a long time (non-involuting congenital hemangioma, NICH). Other rare vascular tumors include Kaposiform hemangioendothelioma and tufted angioma, and both are currently known to cause the Kasabach-Merritt phenomenon.
On the other hand, vascular malformations are developmental errors of vascular morphogenesis without abnormal endothelial proliferation. The lesion is usually present at birth, and grows proportionally to age. Thus, most patients older than children referred to us as having “hemangioma” are indeed diagnosed as vascular malformations. Vascular malformations are divided into subgroups according to the type of vessel or channel abnormality. Capillary (CM), lymphatic (LM), and venous malformations (VM) are slow-flow lesions, while arteriovenous malformations (AVM) are categorized as high-flow malformations. Especially, VM and AVM are increasingly seen by interventional radiologists who provide embolization and sclerotherapy. Although their symptoms are expected to be improved by minimally invasive and repeatable endovascular therapies, the therapies are often technically challenging because of neurological or cosmetic risks. Therefore, multi-disciplinary conference has been recently organized in our institute (Osaka University Vascular Anomaly Conference) dedicated for the management of vascular anomalies including the diagnosis process and therapeutic intervention.

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The aim of functional mandibular reconstruction is to maintain remaining function and to obtain new functions such as by using a dental implant. We have to predict the postoperative function to clarify the aim of reconstruction. This paper evaluates the remaining function of patients who underwent various degrees of mandibulotomy and examines suitable methods to reconstruct them.
This study investigated (1) postoperative occlusal pressure of remaining molars and postoperative diet in patients who received mandibular reconstruction with fibula flap; (2) influence of postoperative function on plate fracture; (3) position of osteotomy of fibula for dental implant; (4) postoperative bone resorption and factors that influence it. The importance of soft tissue graft for contour reconstruction is also mentioned.
Forty-eight patients who received mandibular reconstruction with fibula flap and who were followed up for more than 6 months were examined. As for postoperative diet, it was more strongly affected by the number of remaining teeth than masticatory muscles. Although the patients who had all of the ipsilateral masticatory muscles removed lost their occlusal force conspicuously (39% against normal), if their occlusion stayed about half they could produce an occlusal force of 200N, enabling them to eat an approximately conventional meal. If such patients are reconstructed with reconstruction plate and soft tissue flap, it is highly likely that the reconstruction plate will break. The case in which the mandible was removed to the contralateral canine (or mental tubercle) needed one osteotomy of fibula at the site of the ipsilateral canine for anterior mandible reconstruction. In the case in which the contralateral mental foramen was removed, two osteotomies at the site of both canines were necessary. Annual resorption of fibula was less than 0.2 mm in cases with an occlusal force exceeding 300N, but some factors potentiated bone atrophy. Soft tissue reconstruction in extensive mandibular defects has great significance for functional and aesthetic results. As for the fibula flap, it is required to graft other flap.

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We evaluated patients undergoing long-term follow-up after mandibular reconstruction applied tissue engineering with a bioabsorbable poly L-lactic acid (PLLA) mesh and particulate cancellous bone and marrow (PCBM).
The subjects were 40 patients in whom complete or partial responses were achieved 6 months after this method (malignant tumors: 14 patients, benign tumors: 26 patients). Methods for mandibular resection consisted of marginal resection in 21 patients, segmental mandibulectomy in 16, and hemi-mandibulectomy in 3. The follow-up period ranged from 1 to 12 years, with a mean of 6 years and 2 months. There were no PLLA mesh tray-related adverse reactions. Regenerative bone resorption was less than 10% in 32 patients, 10 to 20% in 6, and 20 to 30% in 2. Bone resorption after 1 year was less marked. In contrast, ossification was advanced in patients achieving bite recovery in the early stage. Usual dentures were applied in 21 patients, and dental implants in 5. This procedure facilitates morphological and functional mandibular recovery, and is less invasive. It may improve bite/masticatory functions in the presence of denture application and/or dental implants.

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We propose a new classification system for segmental mandibular defects after oncological ablative surgery. The system describes a mandibular defect with three letters - C, A and T -. “C” reflects loss of the condylar head of mandible, “A” the mandibular angle and “T” the mental tubercle. The defect is classified as “A” when the mandibular angle is segmentally resected, as “CA” when the condylar head and the mandibular angle are resected, as “CAT” when the entire hemi-mandible is resected, as “ATT” when the angle and the bilateral mental tubercle are resected, as “body” when only the mandibular body is resected and the angle and the mental tubercle are preserved, and as “neck” when only the mandibular ramus is resected and the condylar head and the angle are preserved. This CAT classification system is simple, clear-cut, and a new alternative for oncological mandibular defects.

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Objective: To determine optimal methods of reconstructive surgery for wide defects of the base of the tongue by evaluating the postoperative swallowing function.
Methods: Over half of the base of the tongue was resected while preserving the larynx for 5 patients with oral or oropharyngeal cancer in the Cancer Institute Hospital of JFCR from January 2007 to December 2007. Our reconstructive methods were as follows. Firstly, the active movement of the remaining base of the tongue was confirmed. Secondly, the mucosa of the lower end was closed in order to narrow the pharyngeal space. Finally, a free flap with sufficient bulk was sutured protuberantly. There was no patient with cricopharyngeal myotomy or laryngeal suspension. The postoperative course and the swallowing function were examined.
Results: All patients were able to take food orally. Two of them had recurrence a few months after surgery.
Conclusions: Good swallowing function is expected by our methods. When selecting the surgical method and during postoperative management, it should be considered that some patients have poor prognoses.

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Standardization of reconstruction after removing head and neck cancer is considered to be needed today. A questionnaire survey of reconstructive surgeons was carried out in order to standardize pre-, intra- and postoperative management and outpatient follow-up in the case of free jejunum transfer after total pharyngolaryngoesophagectomy. From July 2007 to September 2007, responses to the questionnaire survey were collected from 13 institutions by e-mail. Including our answers, there were 14 responders in total. The results showed many differences in the management of patients, but most of the institutions agreed on some subjects. Based on these results, what can be standardized so far are: simultaneous execution of tumor resection and jejunum dissection, monitoring of the jejunum, outpatient follow-up by both head and neck surgeons and reconstructive surgeons, and so on. Further investigation is necessary for standardizing the indication of free jejunum transfer, intraoperative management of circulation, intra- and / or postoperative use of PGE1, timing for starting oral intake, and so on.

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Patients with advanced hypopharyngeal carcinoma still have a poor outcome in spite of radical surgery with chemoradiotherapy. We started superselective intra-arterial infusion chemotherapy with concomitant radiotherapy (IA chemoradiation) for advanced hypopharyngeal carcinoma in 2003. The complete response (CR) rate for local and neck lesions was 94.1% and 60%, respectively. After neck dissection the total CR rate was 82.4%. There was no significant difference in survival rates between groups with IA chemoradiation (n=22) and with surgery with preoperative chemoradiotherapy (n=57). However, Kaplan-Meier analysis showed that the cause-specific survival rate in N3 patients and larynx preservation rate was significantly higher in patients treated with IA chemoradiation than in those with surgery with preoperative chemoradiotherapy (p<0.05 and p<0.001). Subjective symptoms are not so severe in patients without the disease after IA chemoradiation. IA chemoradiation is effective for patients with advanced hypopharyngeal carcinoma to maintain quality of life such as voice and swallowing.

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Between April 2006 and January 2008 we experienced 8 cases of mediastinal tracheostomy, and performed a retrospective analysis of the operative procedures and complications. In 6 patients the trachea was transposed to a position above the innominate artery, and in 2 patients the trachea was transposed to the right of the innominate artery. We used the pectoralis major myocutaneous flap for repositioning the major vessels and mediastinum around the tracheostoma. Complications involved a partial necrosis of the tracheal wall in 3 patients, and respiratory failure in 4 patients. In mediastinal tracheostomy it is essential to keep a sufficient supply of blood to the tracheal stump and to protect the major arteries, using a muscle flap if necessary.

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We devised a new method of superselective intra-arterial infusion from the superficial temporal artery for lower gingival cancer. Arterial redistribution by embolization with micro coils was performed in the periphery of the tumor, then two micro catheters were placed superselectively in both the facial and intermaxillary artery.
We applied this technique to a case of lower gingival cancer (T3N0M0). Chemotherapy using intra-arterial infusion (5-FU 100-50mg/m²/day, TXT 15mg/m²/week, CDGP 20mg/m²/week) combined with radiation therapy (total 40Gy) was performed for 4 weeks. The clinical effect was complete response (CR). No operation was performed.
This technique is highly effective for local control with minimal adverse events by using anti-cancer drugs for lower gingival cancer, and showed the possibility of organ preservation.

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We retrospectively analyzed 30 cases with N3 neck metastasis in head and neck cancer treated from 1986 to 2006 in a single institution. The purpose of this study was to evaluate the prognostic factors and treatment options for improving the treatment outcome. Primary sites were the nasopharynx in 9 cases, oropharynx in 6, hypopharynx in 12 and oral cavity in 3. Primary tumor sizes were classified as T1 in 5 cases, T2 in 8, T3 in 9 and T4 in 8. Four cases had distant metastases before the initial treatment. Histopathological examination showed squamous cell carcinoma in 28 cases with 2 cases of undifferentiated carcinoma. The overall survival rate and disease-specific survival rate at 5 years were both 43.4%. Meanwhile, the progression-free neck control rate and neck-specific control rate at 5 years was 34.4% and 55.9%, respectively. In terms of independent predictive factors, statistical analysis showed the primary tumor site, the presence of distant metastasis, the treatment approach (palliative or curative) and the treatment selection. The prognosis of N3 neck disease was poor but can be improved with appropriate treatment options taking the background of patients into consideration.

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We retrospectively investigated 27 patients with cervical lymph node metastasis from an unknown primary site from 1991 to 2007 at our department. Stage distribution was: N1, 0 patient; N2a, 8; N2b, 9; N2c, 1; and N3, 9. Fifteen patients underwent neck dissection alone and eight underwent neck dissection followed by radiotherapy. The overall 5-year-survival rate was 31.0% in all cases and 45.0% in cases who underwent curative treatment. Subsequent primary head and neck tumors were found in four patients. Survival results closely correlated with clinical N stages. It is recommended that radiotherapy of the potential primary site, and postoperative concurrent chemoradiotherapy for patients with advanced N stage should be performed.

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