[in Japanese]

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[in Japanese]

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It is reasonable to reconstruct the new middle ear in which the retraction pocket is difficult to bring about even when negative pressure is generated in the post-operative middle ear cavity, considering the prevention of cholesteatoma recurrence. It is also better to attain dry ears in a short post-operative period and to prevent cavity problems. We began to perform tympanoplasty with reconstruction of the soft posterior meatal wall for the prevention of post-operative retraction pocket formation in 1989. This report presents the surgical procedure and the theory of our method, discusses the advantages of this surgery by comparing two cases with different post-operative middle ear conditions and presenting a third case with retraction cholesteatoma recurrence.

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We have performed canal wall down tympanoplasty with mastoid obliteration as a fundamental surgical treatment for patients with acquired cholesteatoma for complete removal of the lesion and prevention of cholesteatoma recurrence. To avoid postoperative gap formation on the posterior canal wall, canal wall reconstruction using bone pate plate was performed after removal of both the anterior and posterior buttresses. Then the mastoid cavity was thoroughly obliterated with cortical bone slices to prevent the recurrent cholesteatoma. No recurrent lesion has been found on long-term observation after these procedures. Canal wall down tympanoplasty with mastoid obliteration is a useful technique for preventing recurrent cholesteatoma and postoperative mastoid cavity problems.

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The ideal surgical treatment for middle ear cholesteatoma is to create a re-pneumatized middle ear cavity from the Eustachian tube to the mastoidectomy cavity. The canal wall up technique is advantageous in this regard although its reliability for the prevention of cholesteatoma recurrences has always been subject to controversy. This paper describes the surgical concepts to create a communication route from the protympanum to the attic by widening the tympanic isthmus with anterior tympanotomy. Removal of the incus and the head of the malleus helps to maintain its patency in ears with a poorly developed supratubal recess. Erosion of the scutum should be repaired using autologous cartilage. We apply staging operation with placement of silicon sheeting in the middle ear space in ears with irreversibly diseased or absent middle ear mucosa.

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[in Japanese]

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[in Japanese]

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Fifty-two patients with unilateral vocal fold paralysis received intra-fold autologous fat injection. Autologous fat, harvested from the lower abdomen by liposuction, was filtered out and injected through a 19G needle into the vocal fold by endolaryngeal microsurgery. Clinical follow-up including the following parameters was done from one month to three years after the injection : maximum phonation time (MPT), mean airflow rate during phonation over comfortable duration (MFRc), pitch perturbation quotient (PPQ), amplitude perturbation quotient (APQ), and normalized noise energy for 0 to 4 kHz (NNEa). Voice function dramatically improved as compared to the parameters examined before the operation. Injected fat was not absorbed into the surrounding tissue for at least three years. This result demonstrates that intra-fold autologous fat injection by liposuction is simple, and the functional results are durable for patients with unilateral vocal fold paralysis. In particular, this technique was useful in patients whose distance between bilateral arytenoids was more than 10% of the vocal fold length, whose MPT was less than 3 seconds or whose MFRc was more than 400 ml/sec. Indeed, the recovery of voice functions after the injection was satisfactory. If the patient has any glottal gap between vocal processes at phonation before fat injection, fat injection into the oblong pit of arytenoid cartilage can effectively medialize the paralyzed vocal fold. However, when there was a glottal gap between superior and inferior distance at phonation, intra-fold fat injection did not yield successful results.

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For surgical intervention of unilateral vocal cord paralysis, there are several techniques such as thyroplasty type I, vocal cord injection, and arytenoid adduction. Based on analysis of the glottal gap image and vocal function, when a glottal gap width between both vocal processes is more than 10% of the membranous vocal cord length, postoperative vocal function was not favorable. Simulation of each procedure of thyroplasty type I with an expanded polytetra-fluoroethylene (Gore-tex(R)) implant was undertaken on an excised human larynx. When the cartilage wedge was not removed from the window, medialization of the membranous vocal cord was achieved. When the cartilage wedge was removed, medialization of the vocal process as well as that of the membranous vocal cord was achieved. In a case of functional vocal disorder of immobile vocal cords with aphonia, modified thyroplasty type I presented good vocal function.

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We perform vocal cord injection, thyroplasty type I, and arytenoid cartilage adduction as voice function improvement procedures for unilateral vocal cord paralysis. Each surgical technique is selected according to our criteria. Vocal cord injection is performed using atelo-collagen to increase the mass of the vocal cord. The selection between thyroplasty type I and arytenoid adduction is based on the size of the glottic space during phonation and the positional relationship between the right and left vocal cord processes. We compared the glottal area ratio during phonation on NIH images and the results of phonatory function tests using a PS-77E phonatory function analyzer before surgery and those after surgery in patients who underwent thyroplasty or arytenoid adduction, and evaluated the validity of the criteria for the selection of surgical techniques. In patients who underwent a surgical technique according to the selection criteria, improvement was observed in all items (glottal area ratio, maximum phonation time, expiratory aerodynamic power, and phonation efficiency). Patients who underwent a surgical technique not fulfilling the selection criteria also showed improvement in some items but fewer surgical benefits than those who underwent surgery according to the selection criteria. These results suggest the validity of our criteria for the selection of surgical techniques.

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We use CT, MRI, and ultrasound-guided fine needle aspiration cytology for the neck examination of all cases with head and neck cancer. From 1997 to 2001, the occult metastasis rate to the ipsilateral neck was 27% for T1/2 tongue cancer, 36% for T3/4 tongue cancer, 28% for T3/4 laryngeal cancer, and 47% for T3/4 hypopharyngeal cancer. The occult metastasis rate to the contralateral neck was 8% for stage III/IV tongue cancer and 15% for T3/4 hypopharyngeal cancer. The overall metastasis rate to the area of ipsilateral level I, II, III, IV, and V was 45%, 55%, 33%, 7 %, and 4 % respectively for stage III/IV tongue cancer, and was 0 %, 47%, 39%, 21%, and 6 % respectively for hypopharyngeal cancer. The disease-free rate was 91% for the cases with T1/2 tongue cancer who did not have elective neck dissection. Elective neck dissection should be indicated on the basis of these data.

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Background : Sentinel lymph node (SLN) radiolocalization has become one of the most interesting topics in head and neck surgery. We started SLN radiolocalization in N0 neck oral cancer patients in November 2000. Method : Fifteen individuals with previously untreated N0 neck oral cancer participated in the study. The radioactive tracer used was 99mTc phytate. It was injected submucosally around the primary tumor, the day before an operation. Using a hand-held gamma probe on the table, we identified and extracted radiolabeled SLNs before starting a planned surgery. The level of SLN and its count of the gamma probe were recorded. After finishing the planned surgery, we extracted residual radiolabeled SLNs in the dissected specimen again. The SLNs and all other lymph nodes were examined for pathology. Results : Occult metastases to SLNs were found in five patients. In four patients, we found it in SLN with the highest count of radioactivity, and in one patient in SLN with the second highest count. In the case with two positive SLNs, one had the highest count and one the third highest. These SLNs were the only nodes affected. SLNs reflected the patients' neck status accurately. Four of the six positive SLNs in those five patients were micrometastases. Conclusion : We concluded that the sentinel node concept can be applied to the head and neck region. Careful investigation of the highest count SLN to the third is necessary for accurate prediction of the patients' neck status. Considering intraoperative diagnosis of SLN biopsy, a sensitive method which can detect micrometastasis should be established.

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The treatment strategy for retropharyngeal lymph node metastasis is discussed. The surgical anatomy and pitfalls in surgical approaches to the retropharyngeal space are demonstrated. The incidence of retropharyngeal node metastasis in hypopharyngeal cancer varies from 5 % to over 50% depending on the institution. At Tokyo University, it is estimated to occur in about 7 % of all patients and in over 10% of the cases at Stage N or with N stage over N2b. These results indicate that the resection of retropharyngeal nodes is recommended only when the metastasis is confirmed by CT or MR imaging before surgery. From the standpoint of post-operative QOL, prophylactic resection is only suitable in those cases with Stage N diseases.

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In 1906, Crile proposed the first systematic treatment for regional lymph node metastases from head and neck cancer: radical neck dissection (RND) . Since then, the usefulness and effectiveness of RND had been confirmed repeatedly and RND had been made the standard treatment for cervical metastases. The biggest problem with RND was its morbidity ; the loss of the spinal accessory nerve almost always resulted in "Shoulder syndrome." Many surgeons began to modify RND to reduce its morbidity, but the modification process was not easy because it required the same or higher curability as well as lesser morbidity. Only the best surgeons could attain this goal. Their vigorous and constant efforts led to the development of a large variety of new techniques for neck dissection, such as functional neck dissection and selective neck dissection. Today, these function-preserving operative methods play a leading role in surgical treatment of neck metastases. However, because there are now too many operative methods, there is no uniform nomenclature system for them. The indication of each method is different among surgeons. Surgeons are currently trying to standardize the terminology and indication of these modified operative methods.

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A total of 34 patients with squamous cell carcinoma at the anterior wall of the oropharynx was treated between 1992 and 2001. Total laryngectomy was performed in nine patients, and all of them had multiple nodal metastases. These patients were poorer in prognosis with surgery alone than those treated with laryngeal preservation surgery. It took them, however, only two weeks postoperatively to start dieting orally without any deglutition training. It has an advantage in the case of total laryngectomy to be able to leave hospital earlier and to be able to begin further therapy without delay. The issue of deglutition should be assessed on a case-by-case basis, taking account of the extent of extirpation and general conditions including motivation and comprehension. The advantage of total laryngectomy should be disregarded for patients with advanced cancer, especially with extensive multiple nodal metastases.

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Most adults have subclinical cytomegalovirus (CMV) infection, and CMV infection in the adult usually develops in an immuno-compromised host. We experienced a case of intractable multiple ulcers in the transplanted free jejunum caused by CMV in a patient operated for hypopharyngeal cancer. The case was a 68-year-old man who had undergone a total laryngectomy due to laryngeal cancer in 1994 and had undergone a pharyngoesophagectomy because of hypopharyngeal cancer in 2001. Post-operative radiation therapy was applied in a dose of 61Gy by Lineac. In December of 2001 he suddenly developed hematemesis and an endoscopic examination with esophagogastrof iberscopy was done. Multiple ulcers in the transplanted jejunum were found and pathological examination of the biopsied specimen revealed CMV infection with CMV enclosure body.

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