[in Japanese]

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Although orbital blow-out fracture is a common disease, the indications and timing for surgery are still controversial. Since spontaneous resolution of ocular motility disturbance is seen in some cases, observation for up to two weeks is recommended. If the findings of computed tomography (CT) reveal linear fracture with muscular strangulation, operation must be performed urgently. In cases with large orbital floor fractures or early enophthalmos after the injury, early surgical exploration should be considered. Although endonasal or transmaxillary repair of blow-out fracture using endoscopy usually results in satisfactory outcomes, residual enophthalmos is occasionally seen in patients with large bony defects. In such cases, reconstruction of the orbital floor by a transorbital approach is necessary. Optimal surgical timing and optimal surgical approach through careful evaluation of the CT findings and ophthalmologic examinations result in good outcomes.

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This retrospective report details the management of 56 patients with fresh laryngeal trauma treated from January 1971 to December 2008. The causes and number of laryngeal trauma patients were as follows: sports accident 15, traffic accident 13, accident 11, suicidal act 9, work accident 7, and a fight 1. Fresh laryngeal traumas were divided into four groups: penetrating 8, blunt 44, chemical burn 3, and burn 1. Iatrogenic traumas such vocal fold injury, vocal fold paralysis, arytenoid dislocation, and laryngeal granuloma due to intratracheal intubation, endoscopic examination, or laryngomicrosurgery, were excluded. Although blunt and penetrating laryngeal traumas were classified previously by Trone in 1980, there are a few problems in the classification, therefore blunt laryngeal traumas were classified by new criteria. The treatment method was also shown. Group 1 included those patients with endolaryngeal edema or hematomas who should receive conservative therapy. Group 2 consisted of patients with endolaryngeal edema or hematomas and vocal cord mobility disturbance who should receive conservative therapy. Group 3 included those patients with endolaryngeal edema or hematomas and detectable fracture displacement or exposure of cartilage who should receive reposition surgery. Group 4 consisted of patients with endolaryngeal edema or hematomas, detectable fracture displacement or exposure of cartilage and mucosal disruption to be restored who should receive reposition surgery of cartilage and restoration of mucosa. Tracheotomy and stent placement should be suitably performed.

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Inflammatory disorders of neck lymph nodes are very common with the symptom of cervical swelling in children, but congenital disorders should also be considered in the differential diagnosis. We present three representative cases (Kawasaki disease, piriform sinus fistula, and cystic hygroma) and discuss the clinical management for making a differential diagnosis and performing an appropriate treatment. The patient with Kawasaki disease did not respond to antibiotics, but did respond to gamma-globulin and steroid treatment. The case with piriform sinus fistula was admitted to our hospital with a deep neck infection because the diagnosis was delayed. The patient with a recurrent cystic hygroma underwent revised surgical intervention at our hospital and no recurrence was seen thereafter. A number of clinical experiences regarding congenital cystic lesions lead us to conclude that surgical intervention or conservative treatment such as intracystic injection of OK432 can be selected depending on the situation of each patient.

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[in Japanese]

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Generally, the temporal bone with inferiorly located middle fossa is termed the dangerous temporal bone. Anteriorly located sigmoid sinus, which is rarely encountered, is also a type of dangerous temporal bone. We report two patients with an anteriorly located sigmoid sinus. Case 1 was a 51-year-old female with bilateral chronic otitis media. An anteriorly located sigmoid sinus was observed on the right side on preoperative temporal CT. Case 2 was a 28-year-old female with right chronic otitis media. A right high jugular bulb and bilateral anteriorly located sigmoid sinus were observed on CT. We performed lateral tympanotomy carefully in these two patients without massive hemorrhage. It is very important to consider the anteriorly located sigmoid sinus and high jugular bulb to operate the tympanoplasty safely to avoid accidental hemorrhage.

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The purpose of this study was to assess better treatment by comparing the prognosis for patients with early-stage squamous cell carcinoma of the oral tongue treated with brachytherapy or surgery. We examined cause-specific survival rate, recurrence rate and salvage rate to compare the efficacy of high-dose-rate brachytherapy (HDR) and of transoral glossectomy (surgery) performed in our hospital between January 2000 and December 2006. A total of 49 patients with stage I-II squamous cell carcinoma of the oral tongue were divided into two treatment groups: 16 patients in the surgery group and 33 patients in the HDR group. The 3-year survival rates were 94% (surgery group) and 85% (HDR group). Local recurrence rates were 19% (surgery group) and 6% (HDR group), and cervical recurrence rates were 25% (surgery group) and 33% (HDR group). Salvage rates of cervical recurrence were 75% (surgery group) and 55% (HDR group). Therefore, we consider that transoral glossectomy is better than high-dose-rate brachytherapy for stage I-II squamous cell carcinoma of the oral tongue.

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One-step nucleic acid amplification (OSNA) is a new automated systemic method to detect lymph node metastasis by amplifying cytokeratin 19 mRNA, and has the potential to replace the intraoperative histological examination of frozen sections.
The purpose of this study was to develop the OSNA method to identify lymph node metastasis in head and neck cancer.
Analysis of 31 nodes in 13 cases of head neck squamous cell carcinoma was performed with the OSNA method and with routine histological examination.
Of six histological metastatic nodes, five were positive and one was negative according to the OSNA method. All 25 histological non-metastatic nodes were negative in the findings by the OSNA method. The false-negative node was found to be a fully necrotic lesion. Except for this necrotizing node, the OSNA and histological results were identical. According to this study, the OSNA method has the potential to diagnose cervical node metastasis in head and neck cancer.

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We report a patient with a cervical impalement injury caused by a pruned tree branch. Plain computed tomography conducted twice showed progressive emphysema in the deep neck and mediastinum. The branch was extirpated and it was found that the hypopharyngeal mucosa and common facial vein had been penetrated by the branch via the carotid bifurcation without carotid injury. Our findings indicate that CT is useful for detecting injury of the pharynx or major vessels caused by tree branches.

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The reconstruction technique using the contralateral unaffected hemilaryngotracheal flap has been reported to be a simple and effective method with low morbidity and satisfactory oncologic and functional results in pyriform sinus carcinoma resection.
We report a 79-year-old male with hypopharyngeal cancer in the right pyriform sinus, T4aN2bM0, stage IVa. He had a markedly impaired respiratory function caused by comorbidity of chronic obstructive pulmonary disease (COPD). To be cured, he needed radical surgery with a simple and minimally-invasive reconstruction technique, so the reconstruction technique using laryngotracheal flap was applied. He experienced no complications including respiratory disorder, pharyngocutaneous fistula, or pharyngoesophageal stenosis postoperatively.

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For the resection of cervico-thoracic esophageal cancer, we prefer a local excision with free jejunal reconstruction to a total esophagectomy with gastric pull-up, considering the postoperative quality of life. However, we encountered a patient in whom it was difficult to select the surgical procedure due to three problems: 1) The patient's body mass index was as low as 18. Thus, gastric pull-up, which is likely to cause further weight loss, was not encouraging. 2) The patient had undergone an excision of the left half of the sternum plus left ribs of the first and below during the previous surgery for recurrent breast cancer. Therefore, further intervention to the sternum was contraindicated. 3) Excision of the thoracic esophagus to the level of the aortic arch seemed to be essential. After discussion with gastroenterological surgeons, the operation was conducted under the following plan: Try local excision first, and if a safe excision as well as a free jejunal reconstruction is not feasible, perform a total esophagectomy with gastric pull-up as a secondary treatment. The esophagus was circumferentially dissected in the mediastinum and was pulled upward until a safe excision and reconstruction of the thoracic esophagus could be achieved. As s consequence, we successfully accomplished a larynx-preserving cervico-thoracic esophagectomy without any intervention to the sternum. The postoperative course was uneventful and the patient's body weight remains stable one year after surgery. We herein describe the technique and critical points of the surgery.

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Radiotherapy is a good treatment for larynx and hypopharyngeal carcinomas in terms of functional preservation of the larynx, but serious local complications are occasionally caused by radiotherapy, including radionecrosis of the larynx. A study of radionecrosis revealed that the frequency of radionecrosis of the larynx was 2.9%. Clinical features included laryngeal and pharyngeal edema, larynx paralysis, skin ulcer, and dysphasia. 88% of necrosis cases occurred within 18 months after radiotherapy, so radionecrosis of the larynx is a late complication of radiotherapy compared with complications that are recognized relatively early. 38% of the radionecrosis cases were cured by preservative treatment. Operation was necessary in 63% of cases, therefore radionecrosis could have preserved the larynx in 63% of cases. Although radiotherapy is used for preserving laryngeal function, since larynx function is lost as a result, it is necessary to study ways to reduce this complication in future.

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A 73-year-old male was admitted to our hospital for a left neck mass that had persisted for one month. Laboratory investigation revealed slightly elevated lactate dehydrogenase and soluble interleukin-2 receptor (IL-2r). MRI images of the neck revealed multiple neck lymph nodes swelling from the subclavicular to inferior jugular region on the left side. The lymph node of the hilum of the lung was detected by FDG-PET. We performed open biopsy of the neck lymph nodes to rule out malignant lymphoma and diagnosed this lymph node as metastatic acinic cell carcinoma. We performed additional examinations, but there was no primary site of the neck lymph nodes. We diagnosed this disease as metastatic neck lymph nodes of unknown origin and performed radical neck dissection. After the operation, we repeatedly explained the need to search for the primary site of the neck lymph nodes but the patient did not agree. Eight months after the operation, the patient finally agreed to the examination. The PAS level was high and FDG-PET revealed a hot-spot in the prostate. We diagnosed metastatic lymph nodes of prostate cancer, and so performed maximum androgen blockade therapy with LHRH agonist and Bicalutamide. After the therapy, the PSA was within normal limits.

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Carcinoma showing thymus-like differentiation (CASTLE) is a very rare tumor occurring in the head and neck area. The histological view of CASTLE looks like squamous cell carcinoma and lymphoepithelial carcinoma, so it is difficult to diagnose correctly.
The patient was a 23-year-old woman with a swollen mass in the left neck. MRI and PET-CT findings suggested that the tumor existed only in the left lateral cervical area, and no other disease was detected in the whole body. Histological observation by open biopsy suggested metastasis of poorly differentiated carcinoma, so we considered that it was neck lymph node metastasis of carcinoma of unknown primary sites, and an operation was performed. Finally, the resected tumor was diagnosed as CASTLE after immunohistochemical staining positive for CD5 and CD117.
In this very rare case, CASTLE occurred in lateral cervical soft tissue, not the intrathyroidal area. Immunohistochemical staining for CD5 and CD117 is very helpful for diagnosing tumors as CASTLE.

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Desmoid tumor is characterized by benign fibrous growth and develops from the connective tissue of skeletal muscle, fascia and aponeurosis. It commonly occurs in the exterior abdominal wall and the abdominal cavity with the abdominal wall. Cervical desmoid tumor is rare.
A 60-year-old male presented with a large, elastic hard, fixed and non-tender mass in the right neck. MRI revealed a large mass of about 2×3 cm in the right neck, and a biopsy was performed. The pathological diagnosis was extra-abdominal desmoid tumor, so a complete resection was performed.
We describe the clinical course of this case with a review of the literature.

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Gas gangrene in the neck is a serious and life-threatening infection, so it is necessary to diagnose and treat it quickly and accurately. In particular, surgical drainage is very important. We experienced a case of gas gangrene in the neck. The case was a 77-year-old male with the complaint of swelling of the neck and so he was treated by continuous saline irrigation (CSI). After surgical drainage and CSI, the inflammation quickly subsided. CSI was found to be useful for gas gangrene or abscess of the neck.

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We report an unusual case of ectopic cervical thymoma. A 35-year-old female patient presented with an anterior neck mass that developed over a five-month duration. The patient underwent fine-needle aspiration cytology (FNAC) twice, but the tumor type could not be diagnosed. The surgically removed tumor was white in color and had a smooth surface. According to the postoperative pathological examination, the tumor was diagnosed as a Stage I ectopic cervical thymoma and Type B1 according to the Masaoka staging system and the World Health Organization (WHO) histological staging system, respectively. The patient was in good overall health and remained without tumor recurrence at the time of the 10-month follow-up.
Because it was difficult to make a preoperative definite diagnosis by FNAC for the thymoma, we constructed a cell block from the existing cytological specimen. Immunohistological staining using the cell-block method clearly demonstrated the biphasic cellular population pattern that is a characteristic of thymoma. Therefore, this method may be useful as a preoperative differential diagnostic modality for cervical thymomas.

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We report a very rare case of an esophageal submucosal abscess, which was considered to be secondary to a foreign body of fish bone. A 63-year-old male patient had suffered a sore throat immediately after swallowing a small sea bream. Since no fish bones were found in his pharynx or larynx through examination by an otorhinolaryngologist, he was treated with oral antibiotics, but these did not improve his symptoms. He found it difficult to swallow, and a CT scan and MRI revealed submucosal abscesses in the wall of the esophagus. We performed incision and drainage of the submucosal abscesses through an esophageal scope and administration of antibiotics (PAPM and CLDM), resulting in total cure of the patient without reformation of the abscesses.

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