A retrospective study was performed on 31 patients with oral, oropharyngeal and hypopharyngeal squamous cell carcinoma treated by salvage surgery after primary chemoradiotherapy (CRT). Five-year overall survival rates for these patients were 35%. The survival rates for lymph node negative cases diagnosed on the primary CRT were significantly better than those for lymph node positive cases. The survival rates for stage I and II by the restaging on the salvage surgery were significantly better than those for stage III and IV cases. Postoperative complications were found in 45% of the patients. The cases treated by tumor resection with reconstruction surgery showed higher rates of postoperative complications than the cases treated by tumor resection or neck dissection without reconstruction surgery. Furthermore, the outcomes for the cases with postoperative complications were significantly worse than for the cases without postoperative complications. These results suggest that the diagnosis of recurrence at an early stage is important for improving the outcomes of salvage surgery. In addition, in order to reduce the recurrence and salvage surgery, the indication and methods of the primary CRT should be carefully examined.

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Objective: Super-selective arterial infusion and concomitant radiotherapy for patients with head and neck cancer has been increasing in Japan, but there are few reports on salvage surgery after this therapy. We analyzed our experience and evaluated the efficacy and safety of salvage surgery. Design: Analysis of historical collected data. Subjects: 24 salvage surgery cases after super-selective arterial infusion and concomitant radiotherapy. Three cases of primary resection, 16 cases of neck dissection and 5 cases of primary and neck operation. Interventions: More than two times of intra-arterial treatment with cisplatin (100 mg/m²), and radiation therapy (2 Gy/d) 5 times per week for 6 or 7 weeks. Results: The average operation times and blood losses of neck dissection for the cases of after super-selective arterial infusion into metastatic neck lymph nodes were higher as compared with nonirradiated cases. Five salvage surgery cases of primary and neck operation showed postoperative complication in all cases. The estimated Kaplan-Meier 5-year overall survival rates for all patients were 49.4% and cause-specific survival rates were 56.5%. Conclusion: If we choose this super-selective arterial infusion and concomitant radiotherapy, we must examine the risk of salvage surgery.

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Advanced head and neck cancer patients who select concurrent chemo-radiotherapy (CCRT) have increased because they aspire to preserve their organ and function. We carried out CCRT and planned neck dissection (PND) after CCRT because of a high rate of regional failure of CCRT. However, at the salvage operation including PND, severe complications and functional disorder occurred and lasted for a long time. We examined the problems and therapeutic effects of PND after CCRT in about 14 advanced cancer patients of N2b, N2c and N3. In the pathology of specimens, viable cancer cells were observed in 4 cases (29%) and absence of viable cancer cells in 10 cases (71%). The overall complication rate was 8/14 (57%); postoperative bleeding (3 cases), lymphatic fistula (2), foundation infections (1) and dysphagia (3). All the patients survived after CCRT and PND, neck failure occurred in 2 cases (14%) and lung metastasis in 2 cases (14%). In conclusion, PND after CCRT can be an alternative treatment for advanced head and neck cancer. We have to carefully carry out the PND to avoid complications related to such procedures.

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[in Japanese]

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Type I thyroplasty is one of the most standard surgeries for improving hoarseness caused by unilateral vocal fold paralysis. This surgery is technically easy and less invasive than arytenoid adduction surgery. It can be conducted under local anesthesia and the patient can phonate during the operation. This surgical procedure is reversible and highly adjustable, which is a distinctive advantage for phonosurgery. On the other hand, it is relatively difficult for type I thyroplasty to correct a large postglottic gap. In such cases (e.g. maximum phonation time is less than 4 sec.), arytenoid adduction should be considered prior to type I thyroplasty. To perform type I thyroplasty successfully, attention should be paid to the position and shape of the opening on the thyroid ala, separation and preservation of the inner cartilage membrane and insertion of a biocompatible material such as GoreTex^®.

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We report the clinical evaluation and surgical treatment of two cases of glomus tympanic tumor. The first case was a 65-year-old female. She had complained of ear fullness in her left ear for 10 months. The second was a 57-year-old female. She had complained of pulsatile tinnitus and hearing loss in her left ear for 6 years. Otoscopic examination revealed a reddish and pulsatile mass in the tympanic cavity through the tympanic membrane in each ear. The tumors were diagnosed as glomus tumors by otoscopic finding and image findings of computed tomography and magnetic resonance imaging. Preoperative embolization was performed and the tumors were completely resected using the transcanal approach in each case. The total amount of bleeding during the surgery was less than 10 ml in each case. Embolization was very useful for controlling intraoperative bleeding from the tumors.

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Reconstruction with a free jejunal autograft after circumferential pharyngo-laryngectomy for cancer of the hypopharynx and cervical esophagus is generally an accepted method. In our department, we used atypical reconstruction by two-segment anastomosis with a single vascular pedicle and (three end-to-end) anastomosis with intersected jejunum in the mid part of graft, as well as typical reconstruction with end-to-end anastomosis at the oral and esophageal ends. In those atypical anastomoses, two-segment reconstruction was used for the patients with high pharyngeal resection by a patch segment for lateral defect of the oropharynx and a circumferential end-to-end segment. An intersected reconstruction in the mid part was used when the jejunum was relaxing after microvascular anastomosis. To clarify the anastomotic viability of these atypical reconstructions, the day of oral intake after surgery and the cause of delay were investigated for the above three methods of reconstruction, during the period from Oct. 1999 to Mar. 2007 in our department. Fifty-six patients were included in this study, 56 were male and 9 were female, age range 48-89 (average 64.4) years. The average time point of the start of oral intake was 15.1 days after surgery in all cases. In the typical reconstruction (n=52), four cases were delayed and the causes of delay were pharyngeal-end leakage, ileus, subcutaneous hemorrhage and necrosis of cervical skin, respectively. In the two-segment reconstruction (n=8), three cases were delayed and the causes of delay were esophageal-end leakage, ileus and neck abscess. In the intersected reconstruction (n=5), one case was delayed with ileus. These results suggest that atypical reconstruction might not increase anastomotic leakage even though the points of anastomosis increased, and that atypical reconstruction itself might be a viable method of reconstruction.

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We report a patient with recurrent laryngeal cancer after treatment by chemoradiotherapy. He underwent a surgical voice restoration with a free ileocecal patch graft after laryngectomy. The ileocecal patch graft consists of anastomosis of cecum to pharynx, then anastomosis of ileum to trachea. The ileocecal valve is useful for voice restoration and preventing aspiration. The advantages of this method are that it can not only supply more blood to the post-chemoradiotherapy tissue, but also restore the voice at the same time, and the operation technique is simple. The disadvantages of this method are the necessity for and complications of laparotomy operation, complications, and necrosis of free graft. If the adjustment is carried out according to the presence of voice restoration, age, and extent of cancer, the free ileocecal patch graft is useful for improving quality of life in patients after laryngectomy.

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A 64-year-old male complaining of hoarseness was presented. Fiber-optic laryngoscopy revealed a swollen right false cord covered with smooth mucosa. Laryngeal biopsy under direct laryngoscopy yielded the pathological diagnosis of suspected malignant lymphoma. Six months later, the laryngeal lesion increased in size. A second laryngeal biopsy revealed that it was mucosa associated lymphoid tissue (MALT) lymphoma. This case was considered as primary MALT lymphoma of the larynx at stage I E. He was treated by R-CHOP therapy, i.e. standard CHOP therapy with rituximab, resulting in complete response. Low-grade malignant B-cell lymphoma including MALT lymphoma is often left undiagnosed for a long period. It is important to have a close relationship with hematologists and pathologists, so as not to miss the opportunity for treatment.

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Surgery of the parotid gland is one of the most common operations in head and neck surgeries. Identification and functional preservation of the facial nerve is an important procedure in parotid gland surgeries, especially in the case of benign tumors. However, sometimes it is very difficult to identify the facial nerve in the case of recurrent tumors and tumors involving the parapharyngeal space, so-called dumbbell-type tumors. Here we report on the clinical usefulness of Nerve Integrity Monitoring System (NIM-Response 2.0, Medtronic, USA) to preserve the facial nerve function in three parotid gland tumor cases.

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Ectopic thyroid gland is a rare entity caused by failure of descent of the gland anlage early in the course of embryogenesis. It may present with symptoms of airway obstruction, dysphagia or hemorrhage. We encountered a rare case of lingual thyroid with submandibular thyroid gland. A 71-year-old female was referred to our hospital because of dysphagia and sleep disturbance. Indirect laryngoscopy revealed a mass at the base of the tongue. CT of the neck showed two enhanced masses, located at the base of the tongue and in the right submandibular region. There was no continuity between the two masses. The normal thyroid gland was not confirmed. An open biopsy of the base of the tongue and fine-needle-aspiration biopsy of the right submandibular region revealed that the tumor consisted of normal thyroid tissue. We diagnosed them as ectopic thyroid glands. Conservative treatment with levothyroxine sodium (at 150μg/day) was useless for the ectopic thyroid, and the gland enlargement resulted in airway compromise. After she underwent surgical excision of the lingual thyroid, the symptoms gradually subsided. Surgical intervention is necessary for selected patients who become symptomatic or have exacerbation of their initial symptoms while on suppressing therapy.

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Congenital cystic hygroma in infants is a vascular malformation, which can swell up rapidly in a couple of months after birth to compress the respiratory tract, even though the swelling is too small to be noticed at birth. A giant swelling in the head and neck region is a challenge both aesthetically and psychologically for patients and their family, and is a burden to them. The treatment of first choice is sclerosing therapy with OK-432. This paper reports our treatment and the outcome of 15 cases treated in the ENT Division of Chiba Children's Hospital between 1994 and 2005. In the first 3 cases surgical removal was performed. In the subsequent 12 cases from 1998, sclerosing therapy was the a first-choice treatment. One of 12 the cases underwent surgical removal afterwards at another institute because of rapid swelling, which occurred after she caught a cold. In ten of them the size of the cysts decreased by this treatment. Basically, 1 KE of OK-432 was injected into the lesion after aspiration of intracystic fluid under ultrasound guidance, though 2 KE was injected in one case. In several cases the size of the cysts continued decreasing for more than 3 months after injection. Follow-up for 3 to 6 months is indispensable to evaluate the effect of this therapy.

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To examine whether there is a difference in neck dissection after chemoradiation or not, we compared duration of surgery, bleeding and the frequency of complications. Average duraion of surgery, average bleeding and frequency of complications did not differ significantly. However, the frequency of post-operative pharyngolaryngeal edema was higher in cases of post-chemoradiation (p<0.05). Furthermore, we needed to perform reconstruction by dermatoplasty and DP flap in 3 of 4 cases (75%) in the case of irradiation of more than 70Gy. We should pay attention to the surgical procedure more carefully, and particularly to the post operative airway stricture.

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We present a rare case of malignant peripheral nerve sheath tumor of the right neck associated with hypopharyngeal cancer. The patient was a 65-year-old man with a right cervical tumor. On visiting the surgery department, fine needle aspiration revealed adenocarcinoma. The surgery department referred him to the ENT department for further examination of the primary tumor. However, no primary lesion was detected in a chest x-ray, CT, abdominal echography, or endoscopy. The right mid-neck tumor was 5×6 cm in size. Incisional biopsy revealed a malignant peripheral nerve sheath tumor. The lesion was completely excised surgically and the right hypopharyngeal squamous cell carcinoma was excised at the same time, and reconstruction was conducted. The patient died of tumor recurrence 6 months after the operation.

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Since 1985 endoscopic sinus surgery has been carried out by middle meatal antrostomy after temporarily separating the mucosa of the inferior turbinate. The mucosa of the inferior turbinate is stripped, and the maxillary process and the ethmoid process of the inferior turbinate bone are resected, and then the middle meatal opening is made with removal of the uncinate process. To gain a larger surgical field in antrostomy, the middle meatal opening is enlarged to the nasal floor or the lacrimal bone is resected. By this procedure, the large opening facilitates surgery in the antrum in cases of severe sinusitis, antrochoal polyp, postoperative maxillary cyst, benign tumors, orbital decompression on thyroid-related orbitopathy and blow-out fracture. In ethmoidectomy the opening helps to prevent major complications.

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