We report a rare case of an adenoid cystic carcinoma (ACC) of the external ear canal. A 49-year-old man complained of having left ear pain for about one year and had been treated for otitis externa at another hospital before being referred to our hospital for further examination and treatment. The lesion only showed erosion of the skin over the cartilaginous portion of the ear canal. A biopsy of the lesion demonstrated ACC of the external ear canal. This case was classified as T1 according to the Pittsburgh staging system. The patient was treated surgically by partial removal of the external ear canal including a partial parotidectomy followed by radiotherapy (intensity modulated radiotherapy: IMRT). For histological studies, the lesion was considered grade II, in accordance with the classification proposed by Szanto. The Ki-67 labeling index, which provides objective information that determines a malignant potential, was 12.7%.
We also reviewed 47 cases diagnosed as ACC of the external ear canal that were reported in Japan between 2000 and 2010. The majority of these patients complained of ear pain. According to the Kaplan-Meier method, the survival rate in this group would be 89.1% after 5 years and 58.4% after 10 years. 15 of the 47 (29.7%) cases developed local recurrences or pulmonary metastases. ACC of the external ear canal shows poor long-term survival rates. A wide surgical resection is required to cure ACC arising in the ear canal. Patients who have been treated for ACC involving the external ear canal should be followed-up for many years thereafter.

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Giant cell reparative granuloma (GCRG) is an unusual, non-neoplastic fibrous lesion that most often arises in the mandible and maxilla. A differential diagnosis has to be made with that of other osteolytic tumors (giant cell tumors, odontogenic tumors, fibrous dysplasia, etc).
We report on one case with a large GCRG in the maxillary sinus. The patient was a 41-year-old man who came to our department complaining of swelling on the right side of his face. A computed tomography examination showed an expansive mass occupying the right maxillary sinus with some destruction of the orbital floor. The mass included osteoplastic and osteolytic lesions. Biopsy specimens suggested GCRG. The patient received surgical resection, which was followed with an injection of corticosteroids.
We discuss clinical characteristics, differential diagnosis, histological evaluation, and treatment options of GCRG.

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Metastases from renal cell carcinoma to the sinonasal tract are rare. Only 1% of patients with renal cell carcinoma have metastases solely in the head and neck region. We report a case of a 61-year-old man who was suffering from recurrent epistaxis. A dark red and hemorrhagic tumor was observed in the left meddle meatus. Histopathological examination from a biopsy of the tumor revealed clear cell carcinoma. A paranasal CT scan showed a 15-mm-sized soft-tissue mass in the left meddle meatus. A contrast-enhanced viewing showed this mass slightly enhanced. An abdominal CT scan showed a 35-mm-sized mass in the right kidney. We diagnosed this case as metastatic renal cell carcinoma in the nasal cavity. Endoscopic resection of the nasal tumor was performed for an improvement of epistaxis, and then nephrectomy was added by an urologist. At present no recurrent or metastatic lesions have been observed.

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There are different mechanisms of traumatic optic neuropathy, and the degree of disability varies. If the level of disability is high, improvement of visual acuity is not expected with conservative treatment. We report a case of optic canal fracture treated with endoscopic surgery. The patient was a 29-year-old male, who was injured after a fall of less than 8 meters while working on a ship. He was transported immediately to our hospital. He had open fractures to the thigh and elbow, and was admitted for Orthopedic Surgery. Since he complained of vision loss the following morning, he was introduced to ophthalmology and otolaryngology. His visual acuity was only at a hand motion level and his light reflexes had diminished. A CT scan revealed a fracture of the Lt. optic canal. These findings indicated the necessity of surgery and we performed endoscopic optic nerve decompression prior to steroid treatment on the night that this occurred. Visual acuity improved immediately after surgery to a level of being able to count fingers and finally to a level of 0.3. However, visual acuity was not fully recovered. While in this case there was no unified indication of optic canal decompression, it is important to quickly consider whether to perform surgery on a case by case basis. As well as this, Rhinologists who have techniques for endoscopic sinus surgery should take the initiative with regard to treatment, in cooperation with other departments.

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Organized hematoma are benign and non-neoplastic lesions. However, a differential diagnosis using imaging findings from a malignant tumor are extremely difficult. We experienced a hyper-giant maxillary organized hematoma reaching to the other side of the maxillary sinus, which was endospopically treated. Many papers report extra sinus surgery for organized hematoma so as to avoid perioperative bleeding. However, it is possible to lose mass volume step by step in an operation process because organized hematoma are not solid neoplasms. We conclude that even if organized hematoma of the maxillary sinus are huge, they can be successfully treated by endoscopic sinus surgery under an accurate preoperative diagnosis and with careful surgical planning.

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Tumors arising in the parapharyngeal space are rare. We reviewed cases of parapharyngeal space tumors that had been operated on between 1999 and 2010. The pathological diagnosis of these tumors was pleomorphic adenoma (7 cases), schwannoma (3 cases), basal cell adenoma (2 cases), an ossifying fibromyxoid tumor (1 case) and adenocarcinoma (2 cases). Fifteen of the cases had tumors present in the prestyloid parapharyngeal space, and in three were present in the retrostyloid parapharyngeal space. A cervical approach and a cervical-parotid approach were used, but not a mandibular swing approach. All three tumors in the retrostyloid region were schwannoma, and enduring postoperative complications were identified in these patients. Two malignant tumors were in the prestyloid region. Therefore, prestyloid parapharyngeal space tumors should be referred for surgery. However, it appears necessary to be more careful in determining a referral for surgery, by considering symptoms, social background and age of patients with retrostyloid parapharyngeal space tumors.

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We report a case of a sublingual type of dermoid cyst on the floor of the mouth. A 19-year-old man was referred to our ENT clinic because of a swelling of the submental region. It was clinically difficult to differentiate from a thyroglossal duct cyst by using a diagnostic imaging method. We performed surgical resection using a submental approach.
Imaging modalities such as CT, MRI and ultrasonography are useful for diagnosing cystic lesions in the cervical region. However, it has not been easy to make a definitive diagnosis because some cases do not demonstrate typical imaging findings. In our case, it was diagnosed histopathologically as a dermoid cyst.

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Patients with head and neck cancer have a tendency to have metastatic cervical lymph nodes. Some of them develop syncope because of physical compression of the carotid sinus and which have been reported as carotid sinus hypersensitivity syndrome (CSHS). Most of these cases are terminal. We encountered a patient with pharyngeal carcinoma who developed syncope as an early symptom. We surgically removed the cervical lymph nodes and the syncope attack disappeared.
We call the case in which the syncope symptom is caused by a repetition of a carotid reflex carotid sinus hypersensitivity syndrome.
We suggest performing an operation concurrently with chemoradiation therapy (CCRT) and drug therapy as a treatment. Most patients with a metastatic cervical lymph node have advanced cancers. It is suggested that the implantation of a pacemaker is important so as to open up the range of options.

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Malignant melanoma in the head and neck region, which show poor prognosis in spite of multidisciplinary treatment, often originate in the nose and sinuses. We report here an extremely rare case of malignant melanoma originating in the nasopharynx. A 60-year-old man visited our hospital with symptoms of recurrent epistaxis. Nasal endoscopic findings showed that an easy to bleed and black-colored tumor was located mainly in the superior-posterior wall of the nasopharynx, and had also moved into the left nasal cavity and the posterior wall of the oropharynx. The patient underwent surgical resection of the tumor with a left partial maxillectomy. Four months after the first surgery the residual tumor was identified on the roof of the left ethmoidal sinus. The patient underwent anterior skull base surgery. As well as this, the patient underwent a total of 5-cycles of DAV chemotherapy and 50 Gy of radiotherapy. There has been no evidence of gross tumor or of metastasis in the 16 months since the surgery.

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In a paratracheal dissection for a total pharyngolaryngoesophagectomy, it is important to prevent trachea cartilage necrosis, which becomes a trigger for serious complications and for keeping sufficient blood supplied around the trachea. We tried to keep one of four right and left affiliates of the bloodstream from either the superior thyroid artery or the inferior thyroid artery. This was achieved by a method of safely minimizing the creation of the tracheostoma. Moreover, this method was thought to be useful for the management of the tracheostoma and to prevent postoperative complications and stricture, which contributes to the improvement of QOL after a permanent tracheostomy.

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We report on a vocal method technique to improve a Provox2^® voice. The subjects were two patients who had a laryngopharyngectomy with a jejunal graft reconstruction. We examined 3 different vocal methods by using conversational competence, fiberscopy, sound pressure and airflow rate during phonation. The results indicate that patients who had a laryngopharyngectomy with a jejunal graft reconstruction improved their conversational competence, sound pressure and airflow rate during phonation with a new technique by changing a neoglottis figure. The results suggest that this new vocal method technique is useful for patients who have had a laryngopharyngectomy with a jejunal graft reconstruction.

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Almost all metastases to the head and neck area from the body's internal organs are dealt with by distant metastases, and their prognoses are poor. We clinically examined 35 cases of these metastases in patients that visited our department. Primary lesions were from the lungs (10 cases), breasts (six cases), kidneys (four cases), and thoracic esophagus (three cases). There were also two cases from each of the colon, pancreas, liver, and stomach, and one case from each of the prostate, gall bladder, mediastinum, and retroperitoneum. With regard to the state of the primary lesions, 23 cases were untreated and 12 cases had been treated on the first visit. With regard to the location of the metastasis, 28 cases were in the cervical lymph node, and 13 cases were in locations other than the head and neck area.
Five cases had undergone surgical resection. Surgical resection on head and neck area metastasis is rare, and the decision as to whether to refer a patient in this situation should be considered case by case.

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In order to investigate the precipitating factors in the pathogenesis of a neck abscess, we retrospectively analyzed 38 patients with neck abscesses who were treated between August 2008 and July 2010. We also compared their clinical status with 38 patients suffering from peritonsillar abscesses during the study period. The peritonsillar abscesses occurred mostly in patients in their 20s and 30s, whereas the neck abscesses occurred mostly in children aged below 10 and in patients 50 or over. The rate of cigarette smoking was higher for both groups when compared to the general population. Neck abscesses occurred mostly in the lateral or retropharyngeal region, followed by the submandibular region, and in some cases the retropharyngeal abscess extended to the suprahyoid region or the mediastinum. The most common cause of neck abscesses were pharyngitis and cavities in adults, and lymphadenitis in children.

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A parathyroid tumor that induces hyperparathyroidism is a relatively rare disease. However, the numbers being detected have been increasing due to asymptomatic hyperparathyroidism cases discovered by a high value of serum calcium, or by ultrasonography introduced into examinations and clinical surveys.
In this report, a retrospective analysis was performed on 18 patients who have had hyperparathyroidism for the last decade. We analyzed preoperative inspections that detect lesions causing hyperparathyroidism and also pathology. We investigated preoperative and postoperative values of serum intact PTH, calcium (Ca), and phosphorus (P).
In addition, we examined the predictive factor of hungry bone syndrome, which is one of the postoperative complications of hyperparathyroidism.
As a result, it was suggested that ultrasonography, CT and MIBI scintigraphy were useful as preoperative inspections. It was also suggested that a high ALP value of blood could be a predictive factor of hungry bone syndrome.

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Carcinoma arising from a thyroglossal duct remnant (TDR) is relatively rare. We report a case of papillary carcinoma occurring concurrently in the thyroglossal duct cyst and thyroid.
A 51-year-old male visited our hospital with a right supraclavicular fossa mass. CT scanning revealed masses which were present in the midline of his anterior neck and bilateral thyroid lobe. Aspiration biopsy of the cervical lymph node was positive for papillary carcinoma, so TMN classification was considered cT3 (m) N1bM0. A Sistrunk procedure was performed in addition to both a total thyroidectomy and a left neck dissection. Histopathological examination of the surgical specimen showed papillary carcinoma in the thyroglossal duct cyst and in the bilateral thyroid lobe. There were seven cervical lymph node metastases. The patient was discharged without complications.
The problem in this case was whether the carcinoma in the TDR was a primary or a metastatic lesion. The MIB-1 monoclonal antibody reacts with an antigen present within the nuclei of all proliferating cells, but it is absent in the nuclei of quiescent cells. It has been reported that immunohistochemical investigation using the antibody MIB-1 provides useful information on the growth of thyroid lesions. Therefore, we performed an examination immunohistochemically using a monoclonal antibody MIB-1 and assessed the proliferative ability of the tumors. If the MIB-1 labeling index in carcinoma is similar, it will probably indicate a similar cell proliferative ability.
The result was that the papillary carcinomas in the thyroid gland and the metastatic lymph nodes showed average MIB-1-positive cell rates (about 2%), but the carcinoma in the TDR was negative for MIB-1 staining. Also, there was a considerable difference between the cell proliferation of papillary carcinoma in both the TDR and the thyroid gland, and this suggests the possibility that these were multiple primary papillary carcinomas in both the TDR and the thyroid gland.

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We present a rare case of a Warthin's tumor with a skin ulcer. A 98-year-old man was diagnosed with a Warthin's tumor five years ago, and was observed because of his old age. After this, ulceration of overlying skin occurred due to the influence of frequent aspiration of the tumor. Skin disintegration due to a benign tumor is very rare. Skin ulceration of a Warthin's tumor is presumed to occur from an enlargement of the neoplasm, trauma to the skin, and such things as infection or poor nutritional condition. Although a Warthin's tumor is a benign tumor, we must diagnose it and make proper decisions with regard to careful treatment once it is ulcerated.

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We report a surgical case of intraparotid facial nerve schwannoma, which was preoperatively diagnosed as pleomorphic adenoma. A 40-year-old woman was diagnosed with pleomorphic adenoma of the parotid gland by MRI and fine needle aspiration cytology. Surgical excision of the parotid tumor was planned. However, during surgery the tumor was found to originate from the main trunk of the facial nerve. We diagnosed the tumor as facial nerve schwannoma in the parotid gland and performed intracapsular excision of the tumor using electrical intraoperative monitoring of the facial nerve to preserve facial nerve function. We succeeded in a subtotal tumor excision with mild postoperative facial nerve paralysis, which was recovered completely within three months.

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Between 1983 and 2009, 23 patients with adenoid cystic carcinoma of the head and neck were treated with definitive surgery. Twelve patients were male and 11 were female. The mean age of the patients was 64.1 years (with an age range of 28-80). The most common source site was the parotid gland (7 patients), followed by the submandibular gland (5 patients), the oral cavity (5 patients), the maxillary sinus (2 patients), the nasopharynx (2 patients), the mesopharynx (1 patient), and the trachea (1 patient). A retrospective analysis was performed with regard to histological subtypes, treatment, overall survival rate and disease-free survival rate.
The overall 10-year survival rate and 10-year disease-free survival rate were 69.7% and 32.9%, respectively. With regard to histological subtypes, a solid type had a tendency to have a poor prognosis. Also, it was suggested that postoperative radiotherapy could improve local control rates. Although prophylactic neck dissection could reduce cervical lymph node metastasis, it may not affect the long-term prognosis.

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We examined the relationships between hyperkinetic delirium and delirium risk factors, as well as a sedation period or duration in 41 patients after having reconstructive surgery in our hospital from January 2006 to December 2010. Twenty-five of the 41 patients experienced delirium and 16 did not experience delirium. No relationship was observed between postoperative delirium and age, operation time, electrolyte abnormality, or benzodiazepine. However, significant differences were observed in the use of H2 blockers (96% vs. 68%; p < 0.05) and in the average postoperative sedation period or duration (46 hours vs. 31 hours; p < 0.05) between patients experiencing delirium and those not experiencing delirium. We consider that stress to body caused by sedative medication, delays in waking caused by extension of the sedation, and physiologic stress caused by artificial respirator use lead to this postoperative delirium. A reduction in the sedation period or duration is thought to be advisable.

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