[in Japanese]

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[in Japanese]

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[in Japanese]

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The development of sialendoscope has enabled the removal of salivary stones and diagnosis of structures of the salivary duct. The removal of stones has also been facilitated by combining two approaches: additional incisions and transoral procedures.
We started performing sialendoscopy in 2009. A total of 89 cases of sialolithiasis and stenosis in 88 patients were treated during the period from 2009 to 2013. In the sialolithiasis cases, we found the size, location and form of the stones were very important. In the stenosis cases, we treated patients with ductal dilatations by a coronary catheter.
Sialendoscopy is covered by health insurance from this April. This new approach is becoming an effective procedure in Japan.

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The present paper reviews previous specialist exams and points out some problems. The first problem is that many areas overlap between Section A, Cancer Treatment Overview, and Section B, Head and Neck Parts Overview. A major revision of Section B, including the possibility of eliminating the whole section, should be considered. Other problems include uneven numbers of questions among different areas, variations in the style, and lack of instructions. These problems may be resolved by presenting a sample along with a request for exam designing. As for the interview section, the length of time was extended from 7 minutes to 20 minutes two years ago. Some possible issues, such as deciding appropriate questions and unifying evaluation criteria among interviewers, should be addressed in the future.

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[in Japanese]

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Juvenile angiofibroma is an uncommon, benign and extremely vascular tumor. It develops almost exclusively in adolescent males. Compared with conventional surgeries, endoscopic surgery has less intraoperative blood loss, a lower occurrence of complications and shorter length of hospital stay. Cases with extensive involvement of the infratemporal fossa and cavernous sinus, however, can be more appropriately treated by conventional surgeries. Preoperative embolization is effective, but it is difficult to embolize the branch of the internal carotid artery. In such a case, a two-surgeon technique with three or four hands is useful. A partial resection of the middle turbinate facilitates the manipulation of the sphenopalatine foramen and the pterygoid canal. The tumor invasion into the pterygoid canal should be assessed preoperatively, and should not be missed during surgery.

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The anatomy of temporal bone is very complex, with many critical structures closely related with one another. However, most teaching books present two-dimensional images; studying anatomy from two-dimensional representations such as text or video may be insufficient to learn the many spatial relationships that exist within temporal bone. It is important to understand the complex topography of temporal bone and this is the main reason for conducting human dissections during medical training. The possible advantages of multi-view three-dimensional presentations in studying human anatomy have been reported. In this study, we dissected human temporal bone, and developed a system for three-dimensional visualization of the clinical anatomy of temporal bone.

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Endoscopic sinus surgery has been the first choice of treatment for postoperative maxillary cysts (POMC). In some cases, however, postoperative obstruction still occurs. Recently, endoscopic modified medial maxillectomy (EMMM) was reported to be an effective surgery for inverted papilloma and POMC. EMMM is a surgical procedure that preserves the lateral wall of the nasal cavity and nasolacrimal duct, while providing better access to the maxillary sinus.
We performed conventional endoscopic sinus surgery for 17 cases (20 sides) with POMC between January 2012 and December 2012. Of these cases, we performed EMMM in 11 cases (11 sides), of which one case suffered recurrence in the follow-up period.
EMMM is an effective procedure for POMC that occurs in the anterosuperior portion, which is very difficult to reach by conventional endoscopic sinus surgery. EMMM expands the indications for endoscopic surgery.

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1.6% of dermoid cysts of the whole body occur in the oral floor. Usually in Japan, dermoid cysts in the oral floor are divided into three groups according to Hagizaki's classification: subglossal type, submental type and subglossal-submental type. Recently, we treated one patient with the subglossal-submental type of dermoid cyst and another patient with the subglossal type and submental type of dermoid cyst. In consideration of these cases, although Hagizaki's classification is helpful for deciding the surgical procedure for oral floor cysts, we had two questions regarding the classification. The first one is that the submental type, which is anatomically located outside the oral floor, is placed in the category of oral-floor dermoid cysts. The second one is that the anatomical site of the subglossal-submental type remains obscure in the existing literature regarding oral floor cysts. These issues cause confusion in the literature on oral-floor cysts. This paper proposes a revision to the Hagizaki classification to eliminate the problem.

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To evaluate the usefulness of prophylactic neck dissection for stage I/II squamous cell carcinoma of the oral tongue, 110 previously untreated patients with squamous cell carcinoma (SCC) of the oral tongue were retrospectively studied. The 5-year disease-specific survival rate did not differ between stage I (87.1%) and stage II (83.4%). The five-year disease-specific survival rates were 85.9% in well differentiated SCC, 83.9% in moderately differentiated SCC, and 70.7% in poorly differentiated SCC, respectively. Thirty-three of the 110 patients had recurrences, 17 of which were salvaged successfully. Two of the 52 cases in stage I and 33 of the 58 cases in stage II were treated with ipsi-lateral supra-omohyoidal neck dissection (SOND) as their initial treatment. Four of the 33 (18.8%) patients who were treated with prophylactic neck dissection had recurrences, while 13 of the 25 (52.0%) patients without SOND had recurrences. The 5-year disease-specific survival rate did not differ between patients with SOND (80.9%) and those without SOND (79.5%). These results suggest that prophylactic SOND for stage I/II SCC of the oral tongue does not improve their prognosis.

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Sarcomatoid carcinoma is defined as a tumor with areas of definite squamous cell carcinoma as well as a sarcomatous stroma with spindle cells. It is considered to be a typical squamous phenotype.
We report a case of spindle cell carcinoma with rapid progression. The patient was a 58-years-old man who was taken to a hospital by ambulance due to myocardial infarction, and underwent tracheotomy. After extubation, he presented with dyspnea. Bronchoscopy was performed and revealed a polypoid mass in the trachea and subglottic area in the larynx. The diagnosis on biopsy was spindle cell carcinoma of the larynx. Surgical resection was planned for 3 weeks later, however, his tumor developed rapidly. Finally, progression of the disease made us decide to cancel the surgery, and he died 60 days after the diagnosis.

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Bilateral laryngeal paralysis (BLP) leads to respiratory problems such as dyspnea which can cause a critical condition, so it is important to consider whether tracheostomy should be performed as an emergency procedure. This study examined 39 cases (9.6%) with BLP in 405 cases with laryngeal paralysis, including 10 (25.6%) caused by surgeries (7 with cardiovascular disease and 3 with thyroid disease), and 8 (20.5%) idiopathic cases. Cardiovascular surgeons should consider an unexpectedly high complication rate of BLP after surgery. As for treatment, we performed a tracheostomy in 18 cases; the decision as to whether tracheostomy is necessary is often made by an otolaryngologist. We base the decision on dyspneic degree, vocal folds, and causative disease.

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Between 1996 and 2009, 30 patients with adenoid cystic carcinoma of the head and neck were treated in our department. The patients consisted of 17 males and 13 females. Mean patient age was 52 years old, ranging from 24 to 78 years old. The site of the lesion was salivary gland in 12, nasal cavity and paranasal sinuses in 9, oropharynx in 3, external auditory canal in 2, nasopharynx in 1, oral cavity in 1, orbit in 1, and trachea in 1. Cumulative 5- and 10-year disease-specific survival rates in these 30 cases were 74% and 38%, respectively, and the survival rate gradually decreased in the long term. 25 of the 30 patients underwent radical cure; 16 of these 25 patients developed recurrence; 9 of these 16 patients underwent salvage. The 5-year survival rate of the 9 patients who underwent salvage was 54%, while that of the patients who did not undergo salvage was 21%. There was a statistically significant difference between the two. We concluded that patients with recurrence and metastasis should be treated, if possible, to improvement the prognosis.

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A 53-year-old woman with untreated diabetes mellitus (DM) and complaints of severe sore throat, dysphagia and dyspnea was referred to our hospital three days after onset of symptoms. Endoscopic examination demonstrated that the epiglottis and posterior wall of the pharynx were swollen without impaired vocal cord mobility. Blood examination showed elevated CRP (60.2mg/dl) and HbA1c (JDS)(12.6%) levels. CT revealed abscesses spreading into the retropharyngeal space, peritonsillar space, parapharyngeal space, visceral space, carotid space and mediastinum. We diagnosed this patient as having severe descending necrotizing mediastinitis (DNM) secondary to deep neck infection. Cervical drainage and transthoracic mediastinal drainage were carried out. After the drainage, systemic management was performed in an intensive care unit in the emergency department. The patient was given antibiotics intravenously and respiratory management involving endotracheal intubation. Mechanical ventilation was applied. However, reoperation and tracheotomy were required seven days after the initial drainage. After reoperation, drug-induced renal failure, acute heart failure, drug-induced liver dysfunction, colitis, pneumonia, anemia and pleural effusion occurred. We performed intensive treatment including hemodialysis and transfusion with the help of physicians. Fortunately, the patient recovered gradually and was discharged on the 101st hospital day without any sequelae.
We reviewed 68 DNM cases reported in Japan between 2007 and 2012. Seven out of 68 patients died, which is a mortality rate of 10.3%. Statistical analysis demonstrated a significant correlation between prognosis and shock at the first visit. The relationships between DM, odontogenic infection, Endo's classification and prognosis were not correlated.

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Thyroglossal duct carcinoma is carcinoma of thyroglossal duct tissue, but it is not certain whether thyroglossal duct carcinoma originates from such tissue or from metastasis of thyroid carcinoma.
The present case was a 28-year-old woman who had a tumor in the submandibular region. Upon examination, thyroglossal duct carcinoma was suspected, so it was exenterated by Sistrunk's procedure. There was no tumor in the thyroid gland, so the thyroid gland was preserved. The carcinoma was thought to originate from thyroglossal duct tissue.
It has been reported that the thyroid gland should be removed in cases with thyroglossal duct carcinoma, because thyroglossal duct carcinoma sometimes occurs with thyroid carcinoma. However, if fine needle aspiration biopsy of the thyroid tumor is negative, the thyroid gland can be preserved.
Neck CT, FNA and echo can increase the diagnostic rate for thyroglossal duct carcinoma.

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In sialendoscopy, insertion of the endoscope into the duct opening is considered to be the most technically difficult part of the surgical process. We have developed a sheath dilator to facilitate insertion of the endoscope. This device consists of a sheath into which a dilator containing a guidewire is inserted. The device is inserted from the tip of the guidewire into the duct opening and the integrated dilator and sheath can be smoothly inserted. The dilator and guidewire are then removed, leaving the sheath in place. The tip of the sialendoscope can then be inserted through the sheath, gaining easy access to the duct. We believe our new device will make a useful contribution to the field of sialendoscopy.

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Lymph node enlargement is a common manifestation of a variety of inflammatory and malignant diseases, and it is often difficult to make a definitive diagnosis of this state without lymph node biopsy. We retrospectively studied the clinical background of diagnostic biopsies of cervical lymph nodes.
One hundred and fourteen patients with cervical lymph node enlargement who underwent cervical lymph node biopsy during a 7-year period in our department were enrolled. There were 57 men and 57 women ranging in age from 15 to 94 years with an average age of 59.9 years. Medical records were reviewed for the consultation processes, diagnoses, age groups, imaging examinations, blood tests, and FNAC.
Forty-two (36.8%), 61 (53.5%) and 11 (9.6%) patients were eventually diagnosed as having inflammatory, malignant lymphoma and metastatic carcinoma, respectively. The patients' age was higher in the malignant group than in the inflammatory group (p < 0.001). The percentage of malignant diseases was higher in patients aged > 30 years (p < 0.001). CT finding of central necrosis was helpful for diagnosis of metastatic carcinoma. Malignant lymphoma was strongly suspected when the sIL-2R level was > 3000U/mL. The sIL-2R level was correlated with WBC (r = 0.219, p < 0.05), CRP (r = 0.412, p < 0.001), LDH (r = 0.521, p < 0.001), and albumin (r = -0.402, p < 0.001), indicating that the sIL-2R level reflects the state of illness and systemic condition. The percentage of malignant diseases was also higher in class III/IV/V cases than in class I/II cases in FNAC (p < 0.05), but there were still 10 patients with malignant lymphoma in 25 class I/II cases.
These results indicate that cervical lymph node biopsy should be considered to be indicated for patients when malignant lymphoma is strongly suspected based on other clinical examinations. However, the indication of lymph node biopsy should be limited when metastatic malignant tumors are not ruled out.

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The patient was a 67-year-old man. He had been stabbed in the face with a kitchen knife by his son who suffered from schizophrenia, and he was brought to Kyorin University Hospital as an emergency. The kitchen knife reached the contralateral maxillary sinus from the left gena through the nasal cavity. In a computed tomography image, the kitchen knife appeared to have damaged the descending pharyngeal artery and sphenopalatine artery, so we cut open the left neck and prepared for external carotid taping above the superior thyroid artery. We also prepared to stop the bleeding which was hard to stop before extracting the knife. However, we could remove the kitchen knife without bleeding. Furthermore, the patient improved without serious blood vessel damage or facial nerve injury. Here we discuss the clinical presentation of this patient, review the recent literature, and discuss the findings.

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SFT is a rare tumor that generally occurs in the pleura. Recently, SFT has been reported in extrapleural sites including the head and neck region. We report four cases of solitary fibrous tumor (SFT) in the head and neck region. The first patient was a 79-year-old woman, in whom a tumor found in the right side of the trachea by echography or by ultrasonography was removed and was histopathologically and immunohistochemically diagnosed as SFT. The second patient was a 33-year-old woman who complained of epistaxis from a vascular-rich tumor in the left side of the nasal cavity. The tumor was removed through a sublabial approach. The third patient was a 47-year-old man who had been aware of a tumor of 80 mm in diameter located in the right side of the neck, which was surgically resected. The fourth patient was a 63-year-old woman, in whom SFT had recurred several times since 9 years of age and metastasized to the neck. The metastasis was removed by segmental mandibular resection. In all cases, the tumors showed the patternless pattern histopathologically and were positive for vimentin and CD34 immunohistochemically, indicative of the diagnosis of SFT. Although SFT recurred in the lumbar spine two years later in the fourth patient, the other three patients showed no evidence of recurrence following the surgical resection.

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