[in Japanese]

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We report a case of traumatic perilymphatic fistula caused by an ear pick, diagnosed on the basis of pneumolabyrinth seen on a CT scan. A 46-year-old man presented with hearing loss, tinnitus, vertigo, and nausea just after inserting an ear pick into his right ear. A perforation that extended from the anterior inferior quadrant through the posterior superior quadrant of the tympanic membrane was observed. Leftward horizontal rotatory mixed nystagmus was noted. Standard pure-tone audiometry indicated a mixed hearing loss of 96.7dB with an A-B gap of 36.7dB. Temporal bone CT showed low-density areas in the vestibule, lateral semicircular canal, and cochlea, suggesting the penetration of air bubbles. On the basis of these findings, traumatic perilymphatic fistula with pneumolabyrinth was diagnosed. The middle ear was operated on and the fistula was successfully plugged. After the operation, dizziness was alleviated immediately. However, 4 months after surgery, standard pure-tone audiometry continued to show a 75.0-dB hearing level with an A-B gap of 20.0dB.

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A 60-year-old female with squamous cell carcinoma in the right maxillary sinus. Chemotherapy-induced hepatitis B (HBV) reactivation sometimes causes severe hepatitis. HBV reactivation also occurs in patients with negative serum markers for hepatitis B surface antigen. The physician should consult with a liver disease specialist and consider alternative treatment with nucleoside analogues.

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Glomangiopericytoma is a rare tumor that represents less than 1% of all sinonasal neoplasms. The clinical and histologic characteristics of glomangiopericytoma, also called sinonasal hemangiopericytoma, differ from those of hemangiopericytoma developing elsewhere in the body. Accordingly, the World Health Organization (WHO) classified this tumor as a distinct entity in 2005. The patient was a 46-year-old man who presented with epistaxis, and was found to have a mass in the right nasal cavity. Computed tomography scan (CT) and magnetic resonance imaging (MRI) revealed the mass filling the right nasal cavity with extension into the adjacent sphenoid sinus, and bilateral neck lymph node swellings. Positron emission tomography/computed tomography scan (PET/CT) showed low accumulation of F-18 labeled 2-fluoro-2-deoxy-D-glucose (18F-FDG) on the tumor. Two years later, he presented to our department with worsening nasal congestion. Endoscopic examination of the nasal cavity and CT revealed enlargement of the tumor, so a complete endoscopic excision of the lesion was performed. Histological examination showed tumor proliferation of spindle-shaped cells and perivascular hyalinization. These histopathologial findings led to a diagnosis of glomangiopericytoma. Eighteen months after the resection, no evidence of recurrence was noted.

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We report a case of an inflammatory myofibroblastic tumor (IMT) of the sinonasal tract in a 68-year-old man. The patient received a total maxillectomy and postoperative radiation 20 years ago. A granuloma-like lesion occurred from the cranial base and maxillary sinus on the side of resection, and gradually increased. The tumor was surgically resected. Histological examination showed fibroblast-like spindle cells with inflammatory cells. The tumor cells were reactive with vimentin and SMA and negative with ALK, desmin, and cytokeratin. IMT is originally referred to as an inflammatory pseudotumor or plasma cell granuloma.

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A 57-year-old woman with a history of brain infarction was referred to our clinic for evaluation of primary hyperparathyroidism. Cervical ultrasonography failed to localize the pathological parathyroid gland. ^99mTc-MIBI scintigraphy showed an abnormal up-take lesion near the right side of the larynx. CT revealed a 1.5-cm enhanced mass posterior to the right hypopharyngeal pyriform sinus. The mass was removed through cervical incision, weighed 512mg and was pathologically diagnosed as a parathyroid adenoma. Her serum calcium level and intact PTH level returned to within the normal range on postoperative day 1, and did not rise six months after operation. We consider that the ectopic parathyroid adenoma arose from the parathyroid tissue which had been left posterior to the pharynx when migrating from the fourth branchial pouch to the dorsal aspect of the thyroid.

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We retrospectively investigated eight patients with tongue cancer who received therapy between 2000 and 2011 at our hospital but the treatment results were unfavorable. In the analysis, we studied the treatment methods, cause of death, secondary cervical lymph node metastasis, and pathologic characteristics. All patients received surgery, and two patients received additional radiotherapy due to surgically positive margins. Six patients died of secondary cervical lymph node metastasis and two patients died of regrowth of the primary lesion. Histologically, all patients were well differentiated squamous cell carcinomas. In three patients there was perineural invasion and in six patients there was intravascular invasion of the primary tumor. The depth of intramuscular invasion of the primary tumor ranged from 5 mm to 17 mm. In patients with depth of tumor invasion of more than 4 mm or with intravascular invasion at the primary tumor, it is recommended to add preventive neck dissection to prevent secondary cervical lymph node metastasis. We also investigated the biological cancer malignancy (Ki-67) as an important prognosis factor in tongue cancer.

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We performed a prospective analysis of the results of 3 different methods to detect tumor HPV status in 24 untreated oropharyngeal squamous cell carcinomas. PCR-invader, hybrid capture and p16 immunohistochemistry (IHC) staining were chosen for the methods because they are widely available in hospitals without laboratories or in commercial bases. p16 IHC was performed using biopsied specimens for pathological diagnosis and samples for PCR-invader and hybrid capture were collected by brushing from the primary site or directly using a piece of the biopsied specimen. Rates of HPV positive patients in each method were 50% at PCR-invader, 58% at hybrid capture and 61% at p16 IHC. Subtypes of HPV detected by PCR-invader were HPV type 16 in all positive cases. An additional HPV type 67 was detected in one case. Classification functions of the hybrid capture method and p16 IHC when PCR-invader was set as a standard were as follows: sensitivity and specificity of hybrid capture were 100% and 83%, those of p16 IHC were 100% and 75%, respectively. It is suggested that the reason of unsatisfactory specificity in the hybrid capture method was due to the inappropriately lower cut off value of the index, which had been determined using the patients' data on cervical carcinoma. The unsatisfactory specificity of p16 IHC was probably due to false negative cases in PCR-invader or hybrid capture, which were caused by brushing from an inappropriate lesion of the tumor.

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We report a case of undifferentiated pleomorphic sarcoma of the mesopharynx that was detected during an examination for lung cancer.
An 85-year-old man visited our hospital because of a tumorous mass in the mesopharynx that was detected during an examination for lung cancer.
The mass was resected under general anesthesia and was diagnosed as undifferentiated pleomorphic sarcoma. The lung cancer was treated with video-assisted thoracic surgery and was diagnosed as adenocarcinoma. Because the patient had dementia, we did not administer aggressive additional treatment after the two surgeries. Six months later, multiple brain metastases from the lung cancer were detected, and these were treated under γ-knife surgery. One year after these surgeries, recurrence of the multiple brain metastases was noted. Because of the dementia and recurrence of brain metastases, we decided not to administer further aggressive treatment, and the patient died one year and 5 months after the operations.

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Dermoid cysts on the floor of the mouth are relatively rare. We report a 34-year-old man with a cyst on the floor of his mouth. CT and MRI revealed a 6cm × 5cm × 3.5cm cyst in the sublingual space. Ten ml of a viscous reservoir fluid was sucked out through fine needle aspiration and the preoperative diagnosis was a ranula. The cyst was surgically removed using an intraoral approach under general anesthesia, and was found to be a dermoid cyst, not a ranula. Histological diagnosis was also of a dermoid cyst. The characteristics of the non-uniform appearance of MRI T2 intensity imaging, compression and dilatation imaging, and puncture fluid are useful for the differential diagnosis of a dermoid cyst.
The pre-operative diagnosis of and surgical approach used for this disease have been discussed.

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We have applied transoral partial pharyngolaryngectomy (transoral videolaryngoscopic surgery: TOVS), as one of the less-invasive surgical options of a laryngeal preservation strategy, to patients with hypopharyngeal and supraglottic cancer staged at Tis, T1, T2, and selected T3 defined by size criteria. To set up even better surroundings for the aforementioned surgery, since April 2007, we have devised several modifications with respect to the pre-operative examinations, procedures, and instrumentation as follows: 1) transnasal endoscopy with the Valsalva maneuver, 2) CT scanning with the Valsalva maneuver, 3) position of endoscopic camera monitors, 4) pre-operative observation with flexible endoscope using a curved pharyngolaryngoscope, 5) washing with a dimethicone solution, 6) efficient sprinkling of an iodine solution, 7) a choice of distending scopes, 8) efficient trans-nasal vapor evacuation using a Nelaton catheter, 9) a wide choice of fine needle electrodes, 10) a wide choice of hemostatic electrocautery devices, 11) confirmation of surgical margin using laryngomicro scissors, and 12) mucosal defect covering with fibrin glue and a polyglycolic acid sheet (MCFP method). Each of the technical refinements was described in terms of useful tips and advantages, as well as practical limitations.

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Piriform sinus fistula is a relatively rare congenital condition that often causes acute suppurative thyroiditis and neck abscess among young people. The radical treatment for this condition includes a fistulectomy using a cervical approach or, recently, chemocauterization of the internal opening of the fistula by direct endoscopy. In general, radical treatment can be performed only at a certain interval after reduction of inflammation. A 9-year-old boy suffering from swelling and tenderness of the anterior neck was referred to our hospital. Two weeks after reduction of inflammation by incising the neck to drain the abscess, we performed a fistulectomy. Identification of the fistula is the most important step in obtaining a successful surgical result. We were not able to confirm the fistula in the operating field by staining. However, insertion of a wire probe into the fistula allowed detection of the fistula and facilitated the fistulectomy. This method is supposed to be very effective to identify a piriform sinus fistula in the inflammatory tissue.

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We retrospectively analyzed the oncologic outcomes of 45 patients with oropharyngeal squamous cell carcinoma (OPSCC) when treated primarily in our department between January 2005 and August 2012. Our treatment criteria included (1) transoral video-assisted surgery (TOVS) or concurrent chemoradiotherapy (CRT) for T1-T3 OPSCC patients, and (2) extended radical operation or CRT for selected T3 and T4 OPSCC patients. In the case of OPSCC patients in stage III or IV, cause-specific survival of TOVS is significantly better than that of CRT, and TOVS has a better locoregional control rate. In the case of OPSCC patients in stage III or IV, cause-specific survival of p16^INK4a positive cohort is better than that of p16^INK4a negative, although it is not statistically significant. Oncologic results of p16^INK4a negative cohort when treated with TOVS are good, which suggests our TOVS approach may improve the outcome of p16^INK4a negative patients.

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Aggressive infantile fibromatosis is a rare soft tissue tumor which affects young children. Although it is histologically a benign tumor, it usually shows severe local invasion and high recurrence rates after treatment. Therefore, complete surgical excision of the tumor is recommended. However, in the head and neck region, it is sometimes difficult to resect such lesion completely because of an unclear tumor margin and important tissue around the tumor, such as nerves and vessels. In addition, as the tumor sometimes shows spontaneous remission, the indication for radical excision of the tumor is under discussion.
We treated aggressive infantile fibromatosis that occurred in the right mandible of a 2-year-old girl. The tumor invaded part of the mandible. In consideration of shape and function after surgery, we enucleated the tumor and preserved the mandible like a bridge. Although a residual lesion was suspected pathologically, recurrence and increase of the tumor was not noted for 17 months postoperatively, and the patient has a nearly normal appearance and the function is good.

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Liposarcoma is the second most common among soft tissue malignant tumors in adults, after malignant fibrous histiocytomas. However, the incidence of liposarcoma in the head and neck region is extremely rare. Liposarcoma is believed to originate from primitive mesenchymal cells rather than mature fat cells, so liposarcoma seldom originates from fat tissue or lipoma (fibrolipoma). Liposarcoma is divided into five histological types: well-differentiated, myxoid, round-cell, pleomorphic, and dedifferentiated. The prognosis of liposarcoma depends on the histological type; well-differentiated and myxoid types are considered to be low-grade malignancies, whereas the round-cell, pleomorphic and dedifferentiated types are regarded as high-grade. The common treatment of liposarcoma has been complete, wide surgical excision.
We report the case of liposarcoma arising from the oropharynx space in a 68-year-old male. The initial diagnosis (37 years old) was fibrolipoma; after that, fibrolipoma or lipoma recurred 6 times. Then, a malignant change had occurred by the 7th recurrence with well-differentiated liposarcoma, and a histological-type change had occurred by the 8th recurrence with dedifferentiated liposarcoma.

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We report on a case of closure of a pharyngo-tracheal fistula, which had been performed 30 years ago to restore speech after a total laryngectomy.
The patient had undergone radiation therapy for laryngeal cancer about 30 years ago. A tumor survived after treatment, and a total laryngectomy was performed. At the same time, a pharyngo-tracheal fistula was designed using a forearm free flap, and an original voice prosthesis was emplaced. After the operation, there was no evident pulmonary aspiration and vocalization had improved, and the patient was followed up by a local doctor. However, as the pharyngo-tracheal fistula enlarged with age, the patient began to have difficulty both vocalizing and swallowing. He could take only a liquid diet, and had difficulty caring for the prosthesis by himself.
Initial examination revealed a voice prosthesis at the laryngeal fibers in the pharyngeal cavity. The prosthesis was removed, washed, and replaced by the patient himself. When the vocal prosthesis was removed, the trachea could be observed directly below the pharyngeal cavity. The entrance to the esophagus had been reduced to the size of a pinhole.
Surgery was performed to close the pharyngo-tracheal fistula and reform the esophageal opening. At the upper part of the neck, an inverse U-shaped mark was drawn at the height of the root of the tongue, the pharyngeal cavity was fenestrated, and the esophageal entrance was incised at the valve, and the upper layer of the valve's pharyngeal membrane was denuded and sutured to the anterior pharyngeal mucous membrane. The upper tip of the trachea was closed by the folded skin flap of the neck. The raw surface was covered with the pectoralis major flap for reinforcement. The patient was discharged 2 weeks after surgery without any trouble caused by leakage or infection, and was able to take solid diet.

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Stomal recurrence after laryngectomy is one of the most serious issues in head and neck surgery, because of the complexity of its management and also because of its morbidity. We describe the case of a 67-year-old man who was admitted with stomal recurrence after laryngectomy treated in Mie University Hospital. The tumor had invaded the trachea with mediastinal extension. Though the stomal recurrence of the patient was type III according to Sisson's disease classification, he was operated on and the trachea was reconstructed with a pectoralis major myocutaneous flap to elongate the shortened trachea and simultaneously cover the cervical skin defect. Furthermore, postoperative radiotherapy was performed without any trouble. Although the prognosis is still poor for stomal recurrence after laryngectomy, aggressive operation with intensive postoperative therapy might improve the poor oncological outcome.

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Leakage and pharyngocutaneous fistula are among the most troublesome postoperative complications after total laryngectomy and require an unexpectedly long hospital stay for patients. Although surgical closure is the most common treatment for pharyngocutaneous fistula, frequent dressing and complicated management are necessary. We report here the introduction of negative pressure wound therapy (NPWT) to manage the fistula wound of patients after total laryngectomy and a pharyngocutaneous drainage method using a tracheal opening retainer. These approaches avoid contamination by saliva around the wound, and reduce the frequency of dressing (every two days). This method could be effective for patients and medical staff, reducing both stressful procedures and time.

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Adenoid cystic carcinomas occur in the major salivary glands, and laryngeal adenoid cystic carcinomas are rare. We report two cases of laryngeal adenoid cystic carcinomas that occurred in the subglottis and supraglottis. One case is the patient who was admitted with a chief complaint of dyspnea, and showed a significant subglottic stenosis. Pathological diagnosis was adenoid cystic carcinoma. So the patient underwent a total laryngectomy. In the operation, we noticed invasion of the outer membrane of the esophagus. Pathologically the tumor had infiltrated into the thyroid. So postoperative radiation therapy was given. The other case is the patient who was admitted with a chief complaint of hoarseness. A tumor was found in the supraglottis. Pathological diagnosis was adenoid cystic carcinoma, so the patient underwent a laryngectomy. Apparent infiltration into multiple organs was not found, so no additional therapy was given after surgery. The course is favorable in both cases without local recurrence, or distant metastasis.

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We retrospectively reviewed 146 patients to research patterns of lymph node metastasis of head and neck squamous cell carcinomas in both the ipsilateral and contralateral sides, and the risk factors of the contralateral side, as well as to estimate the usefulness of fluoro-deoxy-glucose positron emission tomography (FDG-PET). Lymph node metastasis was confirmed histologically in 60.3% of the patients. The rate of lymph node metastasis of the contralateral side for cN0 was very low. The sensitivity and specificity of evaluation of contralateral neck status with FDG-PET were 58.8% and 96.9%, respectively. Three clinical factors were significantly associated with contralateral lymph node metastasis, suggesting they are significant risk factors.

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Primary liposarcoma of the thyroid gland is extremely rare with only seven cases reported in English literature. We report a rare case of liposarcoma of the thyroid gland. The patient was a 76-year-old woman who came to our hospital complaining of swelling on the right side of her neck. The ultrasound and CT of the neck described the extension of a tumor to the left lobe from the right lobe of the thyroid. A total thyroidectomy was performed for the tumor resection. After the surgery, a well-differentiated liposarcoma of the thyroid was certified histopathologically. External radiotherapy was required for additional treatment due to a poor margin. In spite of the combination therapy, both surgery and radiotherapy, a metastatic tumor occurred in the anterior mediastinum 9 months after the primary treatment. Surgical resection was chosen for further treatment. No recurrent signs appeared on the follow up 13 months later.

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We have successfully treated a case of adenoid cystic carcinoma arising from the cervical trachea by two-stage laryngeal preservation surgery followed by radiotherapy. A 39-year-old woman was diagnosed with dyspnea. Laryngoscopy revealed a tumor posterior to the right tracheal wall. A biopsy and tracheostomy were performed, and a histological evaluation of the tumor showed it to be adenoid cystic carcinoma (ACC). A two-stage surgical approach was designed to resect the tumor and reconstruct the trachea. We removed the tumor posterior to the right tracheal wall and inserted the cervical local flap at the defect to make a tracheo-cutaneous fistula. Three months after the ablation surgery, the defect of the trachea was reconstructed utilizing a hinge flap and anterior chest skin flap. Since the margin of the specimen was microscopically positive for cancer, postoperative radiotherapy was performed. Seven years after the treatment, the woman is surviving and shows no clinical sign of local recurrence and distant metastasis of the tumor. The experience of this case would indicate that our treatment strategy procedure seems to be the method of choice in cases with ACC of cervical trachea.

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Percutaneous ethanol injection therapy (PEIT) has been established as an effective and safe treatment for thyroid and cervical cystic nodules. In this study, 13 patients with fine-needle aspiration cytology-proven benign cysts underwent PEIT. Eleven nodules were thyroid cysts, and two were cervical lymphangioma. The fluid of the cervical cystic nodule was aspirated, and less than 4 mL of sterile 95% ethanol was injected. The pretreatment volume of the cysts was from 3 to 164 mL (average 44 mL) by volume conversion. PEIT was carried out one to four times (median once). The cyst volume after treatment was from 0 to 92 mL (average 8 mL). The volume reduction rate was from 22 to 100% (average 89%). Three patients without subcutaneous anesthesia complained of a local burning sensation at the injection site. The use of subcutaneous anesthesia could avoid the local burning sensation. As PEIT is safe and highly effective, it should be considered as the treatment of choice for benign thyroid and cervical cystic nodules.

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We considered 66 patients, 75 years old or more, with head and neck squamous cell cancer. The 66 elderly patients were operated on at the Kyushu Cancer Center between 2005-2010. Poor performance status (PS3-4) was observed in 10% of the patients, and comorbidity was observed in 77% of the patients. The definitive treatment group was 98% in primary therapy, but in recurrent therapy, palliative therapy was 48%, which has the biggest number of patients. The overall (disease specific) three-year survival rate of the 66 patients was 56% (71%). The survival rate for the PS3-4 group was significantly lower than that for the PS0-2 group. However, comorbidity and complications due to treatment made no significant difference to the survival rate. In the treatment of head and neck squamous cell carcinoma in the elderly, PS was the most important factor, more important than age itself and comorbidity.

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Between June 2006 and June 2012, 405 patients with thyroid tumors, parathyroid tumors, or Graves-Basedow disease were treated with definitive surgery including lobectomies (267 patients), total or subtotal thyroidectomies (126 patients), and parathyroidectomies (12 patients). A retrospective analysis was performed on non-recurrent inferior laryngeal nerves (NRILN) and aberrant right subclavian arteries (ARSA) using the patients' operation records and CT images. Two cases of right NRILN with ARSA were detected (0.49%). A case of right hemi-thyroidectomy is shown, in which a non-recurrent inferior laryngeal nerve was detected and preserved securely by intraoperative neuromonitoring.

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The number of elderly patients with head and neck cancer is increasing. The choice of treatment for them is difficult, because there is no definitive criterion for decision making. In this study, we retrospectively analyzed our clinical practice for 173 elderly patients, who are 75 years old or more, during the period from January 2002 to December 2011. We discuss the strategy for choosing the appropriate method of treatment.
For 41 out of 51 patients with laryngeal cancer, radical treatment could be appropriate with good outcomes. Decision making for laryngeal cancer is relatively easy. However, the choice of treatment for patients with oral, hypopharyngeal or oropharyngeal cancer is quite complicated, especially, for those patients who are 80 years old or more. In this category of patients, less than half could be subjected to radical treatment. Radical treatment could not be considered the appropriate choice in 63% of the patients due to comorbidities.
These results indicate that in elderly patients with head and neck cancer it is important to choose the appropriate treatment after careful and intensive evaluation of comorbid systemic diseases.

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