First bite syndrome (FBS) after surgical removal of tumors of the parapharyngeal space has been reported recently. According to the literature, the cause has been estimated to involve interruptions of nerves during the surgery around the superior cervical ganglion and sympathetic nerve plexus of the external carotid artery, which cause supersensitivity of parasympathetic nerves in the parotid gland. Excessive contraction of myoepithelial cells in the parotid gland due to parasympathetic supersensitivity leads to the development of a sharp pain in the parotid region. This report includes exclusive cases of sympathetic neurilemomas of the parapharyngeal space that we had treated, along with a discussion of etiologic factors and the background of FBS.

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A retrospective review of 145 previously untreated patients with squamous cell carcinoma (SCC) of the tongue was performed. All these cases were with no regional and distant metastasis. They were treated in the Kyushu Cancer Center between March 1972 and July 1998, and received interstitial irradiation, an operation, or an operation or interstitial irradiation after arterial infusion chemotherapy via superficial temporal artery combination external irradiation as initial treatment for primary lesion (tongue). The scope of external irradiation included the submandibular nodes and the upper jugular nodes. They did not receive prophyiactic neck dissection except the cases requiring reconstruction of the tongue and floor of the mouth. The five-year survival rate (5YSR) calculated by the Kaplan-Meier method was 82%. Recurrence occurred in 59 patients, of which 21 cases were local, 37 cases were regional and one case was distant recurrence. The 5YSR of local recurrence cases was 61%, that of regional recurrence cases was 56%, and that of distant recurrence cases was 0%. Neck dissection was performed for 35 patients of 37 regional recurrence cases, of which 31 patients were salvaged and 4 patients were uncontrollable. The regional control rate by neck dissection after regional recurrence was 89%. The N stage of the uncontrollable 4 patients was more than N2b. These results suggest that the early detection of regional recurrenceis important.

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Fifteen patients with oral and oropharyngeal cancer who underwent en-bloc resection with subsequent reconstruction of the oral floor by suture of the platysma and digastric muscle without free flap were reviewed. We analyzed the treatment method, clinical course, complications and quality of speech by the 10-point scoring system of Hirose. En-bloc continuous resection of the primary lesion and neck dissection were performed by the pull-through procedure or commando operation. We separated the excised cervical wound and oral cavity by suturing between the platysma and the digastric muscle. The primary lesion was located on the oral tongue in 8 patients, on the lower gum in 4 patients, on the oral floor in 2 patients and on the tonsillar f ossa in 1 patient. The patients consisted of 13 males and 2 females, with ages ranging from 28 to 81 years and a mean age of 63 years. Tracheostomy was performed in 6 patients. Five patients with lower gum or oral floor cancer underwent mandibulectomy. Two patients had received radiation for previous head and neck cancers. The mean operative time was 290 minutes. The mean volume of blood loss was 227ml. Complications occurred in 6 patients. Local small abscesses occurred in 3 patients, mild laryngeal edema occurred in 1 patient, mild laryngeal edema and a fistula occurred in 1 patient, and aspiration pneumonia occurred in 1 patient. The mean period until oral intake was 15 days. Speech intelligibility was excellent in 14 patients and moderate in 1 patient. This method is useful and effective. In advanced oral or oropharyngeal cancer requiring reconstruction by free flap, we partially use this method. But for better functional improvement, exclusive use of a free flap is much better. The indication of this method should be carefully decided.

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Two cases of bilateral neck dissection underwent external-internal jugular vein anastomosis to preserve the blood flow of the internal jugular vein following a bilateral neck dissection. The anastomosis between internal and external jugular veins was carried out from side to side in the first case and end to side in the second case. Post-operative complications of a massive facial edema and intracranial hypertension were not observed in both cases. External-internal anastomosis is useful for cranial venous drainage. Preservation of the external jugular vein during neck dissection is important in order to reconstruct the internal jugular vein.

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This study presents the results of salvage surgery for patients with local recurrence of hypopharyngeal carcinoma after radical radiotherapy. Between 1986 and 2002, 85 patients with hypopharyngeal carcinoma were treated with radical radiotherapy. Eight of these patients (Stage I in 3 patients, Stage II in 1 patient, Stage IV in 4 patients) underwent total laryngopharyngectomy as salvage surgery. Four patients (Stage I in 2 patients, Stage II in one patient, Stage IV in 1 patient) were successfully salvaged with no recurrence. Two patients died of distant metastases with local-regional control, and 2 patients died with local recurrence after salvage surgery. Five patients had reconstruction of the pharynx with a pectoralis major myocutaneous flap and one patient had reconstruction with D-P flap. A free jejunal graft was performed in 2 patients. All cases except one patient reconstructed with a free jejunal flap, suffered from pharyngocutaneous fistula. Salvage surgery for local recurrence of hypopharyngeal carcinoma after radical radiotherapy should be selected with distinct determination and informed consent because of the high rate of surgical complications and possibility of local or distant failure.

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We retrospectively examined 27 skull base surgeries for nasal-paranasal sinus malignancy treated from 1992 to 2003 in Chiba University Hospital. There were 22 anterior and 5 middle skull base invasions. Eight out of 27 presented with dura mater invasion. The most frequent pathologic entity was squamous cell carcinoma (n=9), followed by 8 epithelial tumors (4 adenocarcinoma, 3 adenoid cystic carcinoma, and 1 malignant melanoma). Ten non-epithelial tumors encompassed primitive neuroectodermal tumor (PNET), 2 chondrosarcoma, 1 osteosarcoma, 1 f ibrosarcoma, 1 rhabdomyosarcoma, 1 olfactory neuroblastoma, 1 malignant glomus tumor, and 1 malignant fibrous histiocytoma (MFH). Patients with epithelial carcinoma were treated with radiotherapy (60 Gy) before skull base resection. Postoperative complications were reported in 7 patients (26%), with local wound infection as the most common (19%). The cumulative 5-year survival rate of 18 cases treated from 1992 to 1999 was 67% in both epithelial and non-epithelial malignancies. The 5-year absolute survival rate was 79% in the anterior skull base resection, and 25% in the anterior-middle and middle skull base resection. The 5-year absolute survival rate for patients with and without dural invasion was 43% and 91% respectively. Multivariate analysis showed that dural invasion and middle skull base invasion had a significant impact on relapse-free and disease-specific survival. These data indicate that patients with anterior skull base malignancies can be treated successfully with skull base surgery.

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We report the results of superselective intraarterial CDDP infusion therapy with an implantable reservoir system combined with radiotherapy for 5 patients with maxillary carcinomas. The catheters for intraarterial infusion were inserted from the facial artery in three patients and from the superficial temporal artery in 2 patients. The technique of catheterization from the superficial temporal artery was easier than that from the facial artery and obstruction of the artery happened in 2 patients using the facial artery. The dose of CDDP was 100mg/m² and infusion was performed from 1 to 6 times. A neutralization agent (sodium thiosulf ate) was also infused by a reservoir system implanted in the forearm. Conventional external beam irradiation was used to a total dose of 50 Gy in all patients. Complete or partial responses were obtained in 4 patients and these patients received partial maxillectomy. We conclude that the implantable reservoir system for both CDDP and STS administration is an easy, low-invasive method for intraarterial infusion therapy and is especially useful in patients with maxillary carcinomas.

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We report a case of mucocele of the frontal sinus treated with reconstruction of the skull base. The patient showed swelling of the left side of the medial ocular angle and was diagnosed as mucocele of the frontal sinus. At first, endoscopic sinus surgery was carried out and the mucocele was unfolded into the nasal ' cavity. However, acute frontal sinusitis with MRSA emerged and this inflammation spread to dura mater. Debridement of the frontal sinus granulation and reconstruction of the anterior skull base by a galeo-pericranial flap were performed with craniotomy. It is an effective method to shield the cranial cavity from the nasal cavity by utilizing a galeo-pericranial flap to prevent infection from the frontal sinus from spreading to the cranial cavity.

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A 16-year-old boy, while playing basketball, was hit by an elbow in the right orbital area. He sustained diplopia, nausea and vomiting with minimal soft tissue signs of trauma and visited our clinic on the same day. Marked motility restriction was present in up-and-down gaze. Computed tomography scanning revealed a small crack on the orbital floor. There was no improvement at 7 days, and at 14 days after the accident he underwent surgery via the transmaxillary approach. Intraoperatively, the author found that the inferior rectus muscle was severely herniated and was ischemic and edematous. Although these findings suggested a poor prognosis, the diplopia disappeared 5 months after the surgery. Jordan et al. described the "white-eyed blowout" fracture in 1998. This is an important subgroup supporting our clinical knowledge that young patients with marked diplopia without severe soft tissue signs of trauma sometimes require urgent surgery. Operative findings of the severely herniated extraocular muscle in the white-eyed blowout fracture are so significant that all related physicians should be well educated and never miss the timing of surgical intervention.

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Glomus tumor of the nasal cavity is a rare entity; only 19 cases have been reported. We report a case of a 45-year-old woman presented with a lesion at the ethmoidal sinus associated with nasal obstruction. After embolization of the maxillary artery, the tumor was completely removed by the lateral rhinotomy approach. Tumor recurrence was not found over a period of twelve months.

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We report four cases of squamous cell carcinoma in the thyroid gland in which incidence of malignant thyroid tumors is reported to be less than 1 %. Case 1 showed pure growth of squamous cell carcinoma. Cases 2 and 3 revealed coexistence of squamous cell carcinoma and papillary carcinoma. Case 4 involved lymph node metastasis of squamous cell carcinoma-like findings in the undifferentiated carcinoma in the thyroid gland. All cases were ranked as T4 because of invasion to organs including the esophagus or thyroid cartilage. In spite of extended surgery, 3 of the 4 cases died of the disease within several months after surgery. It is likely that the appearance of squamous cell carcinoma derived from the thyroid gland adversely affects the prognosis of the patients and is a prognostic factor, and an intensive treatment system as well as early diagnostic system need to be established.

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Some critical pathways (path) for various diseases are reported so as to shorten hospitalization, improve medical treatment, standardize treatment, and educate medical staff. We started the path for seventeen patients with thyroid cancers from May 2003. The objective of this study was to compare the length of stay (LOS) and complications before and after implementation of this path. We observed a significantly shorter LOS and no increase of complications after implementation of this path. This path is useful for thyroid cancer treatment.

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We report a case of ectopic parathyroid adenoma in the upper mediastinum. A 51-year-old Japanese woman presented hypercalcemia and repeated pancreatitis. The serum parathyroid hormone level was high and Tc-99m methoxyibutylisonitrile scintigraphy showed an abnormal hot-spot in the left side of the upper mediastinum. Therefore, an ectopic parathyroid adenoma was diagnosed. A dark red tumor of 18 mm in diameter located in the thymus was resected under general anesthesia. Postoperative condition was good, with the levels of serum calcium and parathyroid hormone maintained within normal limits. This case indicates that Tc-99m MIBI scintigraphy is highly recommended for detecting parathyroid tumor in an ectopic area.

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Cervical lymph node metastasis of papillary carcinoma of the thyroid gland is common whereas retropharyngeal lymph node metastasis is rare. Strategies for treating retropharyngeal lymph node metastasis must be considered based on the balance between the radicality of the disease and the quality of life after treatment.? Here, we report a case of papillary carcinoma with bilateral retropharyngeal lymph node metastases in a 66-year-old male. This patient presented with lumps in the neck. Computed tomography showed thyroid cancer with multiple cervical lymph node and bilateral retropharyngeal lymph node metastases. Hemithyroidectomy with neck dissection was performed and the retropharyngeal lymph nodes were successfully dissected only by a cervical approach without any severe complications.? We discuss here the problems encountered in the diagnosis and treatment of retropharyngeal lymph node metastasis of papillary carcinoma of the thyroid gland. The possibility of metastasis to this region should be considered in the treatment of thyroid carcinoma with multiple cervical lymph node metastases. The appropriate choice of surgical approach is crucial to improving the post-operative quality of life of these patients.

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From 2000 to 2002, 5 patients with hypopharyngeal carcinoma at Ti and T2 underwent laryngopharyngectomy which preserved laryngeal function. Tumor stage was 3 for T1, 2 for T2, 3 for N0, 1 for N1, and 1 for N2b. All the primary sites were the pirif orm sinus. After lateral neck dissection of the diseased side, it goes into the pharynx on a hyoid level, and the pirif orm sinus was removed with setting to clarify visualization of the tumor. A margin of about 2 cm was attached. We performed complication ablation of a quarter in hyoid and thyroid cartilage of the diseased side. If the arytenoid cartilage had no invasion of tumor, it was preserved. The defect part was reconstructed with the forearm free flap in all examples. As a result, at 15-37 months postoperation, all of the cases are satisfactory for primary control and ingestion of staple foods is possible.

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A case of posterior glottic adhesion caused by recurrent endotracheal intubation was reported. An 81-year-old male was repeatedly intubated four times due to heart failure. Thereafter, he complained of inspiratory dyspnea. Endoscopic examination of the larynx revealed bilateral vocal cord immobility and interarytenoid adhesion. Under general anesthesia, the adhesion was cut, and the left vocal cord was laterof fixed by Ej nell's technique to prevent a recurrence of adhesion. Eighty days after the operation, the left vocal cord was released from the fixation by a cut of nylon thread. The postoperative course has been positive with a good phonatory and respiratory function 10 months after the surgery.

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Usually, the primary treatments of traumatic laryngeal injuries including scar tissue removal by median laryngotomy, transposition of mucosa, T-tube placement, and cartilage graft require quite complicated surgical techniques or repeated surgeries. We applied techniques of a vertical partial laryngectomy with an S-shaped anterior cervical incision used for laryngeal cancer treatment to traumatic laryngeal injuries in adults, and formed laryngeal fistula. These procedures enable us to preserve the voice function and to close the trachea stoma. This surgical method is an effective tool for traumatic laryngeal injuries in adults as we can reconstruct the inner surface of the larynx easily and consistently.

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Congenital ossicular malformations have been dealt with as a common disease recently as school medical examinations have become more commonplace, and the disease is now easier to detect and also the surgery has a higher success rate. The clinical course and treatment results for our series of congenital ossicular malformations were examined. We focused on 4 cases of congenital ossicular malformations that underwent surgical treatment at Nara Medical University Hospital and a related hospital for three years from 2001 to 2003. During the operations, 3 patients showed a group II malformation and 1 patient showed a group uI malformation by Funasaka's classification. Patients 1 and 2 underwent a type IV-i tympanoplasty, and patients 3 and 4 underwent a type III-i tympanoplasty. Regarding the hearing improvements after surgery, 3 patients among the 4 (75%) had a successful result from the operation according to the guideline of Otological Society of Japan for postoperative hearing results. Intratympanic lesions and the condition of the ossicula have become a winning strategy for conclusive diagnosis of congenital ossicular malformations.

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An aerrant internal carotid artery (ICA) with chronic otitis media is reported in this paper. The patient was a 58-year-old female. A pulsatile mass was seen through the perforation of the tympanic membrane, and CT scan showed a defect of the lateral bone of ICA. Type I tympanoplasty was performed and the aberrant ICA was covered with auricular cartilage. Here we discuss the clinical presentation, radiographic investigations and management of this patient.

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Pulmonary embolism (PE) is a prominent cause of morbidity and mortality in surgical patients. Here, we review head and neck surgery. PE was diagnosed three days following surgery after the patient complained of dyspnea while walking. PE was successfully treated by intravenous administration of heparin. Despite prophylactic measures taken during surgery, the prognosis was poor for this patient due to numerous high-risk factors (e.g., advanced age, obesity, prolonged immobilization). Although the incidence of postoperative PE in our department during the last seven years is very low (0.04%), the frequency of postoperative PE in Japan has steadily increased in recent years. PE still is one of the most significant complications leading to morbidity and mortality following surgery. We examined the guideline on prophylaxis of perioperative DVT for Japanese patients, and concluded that otolaryngologists, head and neck surgery should be reminded of high-risk factors associated with PE and be made aware of prophylactic treatments newly aimed at reducing the frequency of PE.

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[in Japanese]

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