The subject was a 68-year-old male. He visited our hospital with the chief complaint of a sore throat and abnormal laryngeal findings were observed on upper gastrointestinal endoscopy. According to the findings of a biopsy at the swelling site of the right epiglottis, adenocarcinoma was suspected and subtotal resection of the epiglottis was performed. The pathological diagnosis was a neuroendocrine tumor （atypical carcinoid）, and because the resection stump was positive, an additional resection （cervical incision） and laryngeal suspension were performed at the same time. As of 1 year and 4 months after surgery, no recurrence or metastasis has been observed and the swallowing function is well preserved. Laryngeal atypical carcinoid develops submucosally, so it takes some time to diagnose the disease. Surgery is the most effective treatment, and extensive resection is necessary because of the submucosal development, which may sometimes cause dysphagia. In this case, since the stump was found to be positive during the initial operation, additional resection （cervical incision） and surgery to improve the swallowing function were performed, resulting in a good outcome.

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We report a case with unresectable poorly differentiated thyroid cancer and distant metastases following multiple recurrences, in whom survival was improved by treatment with the tyrosine kinase inhibitor lenvatinib. A 52-year-old woman underwent total thyroidectomy as well as ablation. She then had further surgery for repeated lymph node recurrences, but lung and bone metastases developed, making her disease inoperable at the third recurrence. A partial response was achieved by administration of lenvatinib together with palliative care, and survival benefit was obtained without exacerbation of neck and lung metastases until she died five months later. A review of the literature is also made.

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Endoscopic-laryngeal pharyngeal surgery （ELPS） is a very effective treatment for early cancers, especially because operation time can be reduced, as well as because unnecessary chemoradiotherapy can be avoided. On the other hand, it was not until ELPS became widespread that early cancer could be eradicated with chemoradiotherapy. With progressive improvements in accurate endoscopic imaging, it has been become possible to detect early recurrence in patients who had previously been treated with chemoradiotherapy. However, when such patients are operated by ELPS, we sometimes encounter difficulties, including difficult device manipulation, unexpected advance of tumors, and obscure tumor margins. We present an analysis of our ELPS cases and identify the problems of ELPS performed after radical chemoradiotherapy.

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This study presents the results of patients who underwent salvage surgery for local recurrence of hypopharyngeal squamous cell carcinoma （SCC） after definitive radiotherapy （RT）, chemoradiotherapy （CRT） or bioradiotherapy （BRT）. From 2005 to 2014, 170 patients with hypopharyngeal carcinoma were treated with definitive RT, CRT or BRT. Of the 45 patients （26.5％） who developed local recurrence, 32 underwent salvage surgery. The types of surgical procedures included total pharyngolaryngectomy （n＝17）, partial pharyngectomy （n＝8）, and transoral surgery （n＝7）.
The three-year overall survival rate of patients after the salvage surgery was 71.3％, with a median survival period of 23 months. Among these patients, postoperative complications occurred in 18 patients （56.3％）.
Therefore, we conclude that salvage surgery is an effective treatment for improving the prognosis of patients with local recurrence of hypopharyngeal SCC, and it is important to understand all of the advantages and disadvantages of total pharyngolaryngectomy, partial pharyngectomy, and transoral surgery, in order to select an optimal treatment for each specific case.

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A retrospective study was conducted to evaluate the clinical outcomes of 32 patients with advanced squamous cell carcinoma of the tongue in our hospital between January 2010 and December 2013. All patients underwent surgical resection. Patients who had microscopically involved resection margins， extranodal extension-positive，pT4，or pN2-3 underwent postoperative chemoradiation therapy. The 3- and 5-year overall survival rates were both 100％ in stage Ⅲ, and 74％ and 64％ in stage Ⅳ. The overall survival rates in patients with microscopically involved resection margins and/or extranodal extension-positive were significantly lower than in the others （p＝0.04）.

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Many Japanese reports use the Japanese Otological Society （JOS） criteria 2000 or 1987 for evaluating the results of stapes surgery. The advantage of Amsterdam Hearing Evaluation Plots （AHEPs）, reported by J. G. De Bruijn for the evaluation of hearing gain, is the ability to evaluate hearing gain with overclosure and higher frequency hearing. In this report, we compared postoperative results using the JOS criteria and AHEPs, and found no difference between them. However, by using AHEPs, we found we could discriminate excellent cases among good cases. We also found that cases showing a low density area in the retrofenestral region on the CT tended to have poorer postoperative results; this was not revealed when we used the JOS criteria. We consider AHEPs to be a suitable method for detailed evaluation of otosclerosis.

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Endoscopic endonasal surgery （EES） has become increasingly popular for the resection of skull base tumors. This approach provides access to the skull base with significant advantages over conventional surgical methods due to better visualization and cosmesis, resulting in shorter hospital admissions and reduced risk of postoperative pain and neurological complications. Although numerous studies have been published detailing complications of EES, few studies describe complications other than cerebrospinal fluid leakage. One of the most devastating complications is massive hemorrhage due to injury to the internal carotid artery （ICA）. The incidence of ICA injury is rare in endoscopic sinus surgery （ESS）, but is more prevalent in EES that involves resection of skull base tumors. During EES, surgeons must have anatomic knowledge of ICA with regard to the operative field and have strategies for dealing with inadvertently inflicted injury to the vessel. There remains significant concern about the ability to manage such injuries when working with an endoscope through a limited operative field. Here we present a patient who suffered from ICA injury during EES for pituitary adenoma, and evaluate strategies for managing ICA injury during EES.

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The surgical technique of stapedotomy using an artificial piston after removing the superstructure of stapes for otosclerosis has prevailed for more than 50 years. During the procedure, an unexpected stapedectomy or floating footplate that may impair the function of the inner ear sometimes occurs. To avoid the risk of inner ear complications, a novel stapes surgery technique was developed.
The concept of the novel technique of stapes surgery is to remove the lenticular process of incus instead of removing the superstructure of the stapes to restore the conduction of the ossicular chain. A Schuknecht Teflon wire piston is then inserted into the small fenestra of the footplate passing between the crus of stapes.
Since 2004, 48 cases have undergone this surgery. Among the 48 cases, 40 cases followed for more than one year were evaluated. The results of average air conduction hearing gain were 18.9 dB, and the number of cases of air-bone gap closure of 20 dB or less was 36 （90％） while the hearing acuity remained stable for over five years.
In conclusion, this novel stapes surgery that preserves the stapes is an easy, safe and timesaving technique.

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Immune checkpoint inhibitors were approved for the treatment of malignant melanoma in Japan and are now used to treat patients with metastatic malignant melanoma for which there had previously been no effective treatment and a mortality rate of 100%. We used ipilimumab, a recently approved immune checkpoint inhibitor, to treat four patients with malignant metastatic mucosal melanoma of the head and neck with all primary lesions located in the nasal cavity. All patients received four rounds of treatment. We subsequently examined the course of treatment based on the primary therapy, response to immunotherapy, and adverse effects. The primary therapies were surgical removal, carbon ion radiotherapy, radiotherapy and chemotherapy. The response to treatment was one patient was declared cancer-free, one patient survived but showed signs of progression of the melanoma, and two patients did not survive treatment. One of the surviving patients developed grade 3 hypopituitarism. Thus, ipilimumab substantially improved the survival rate of patients with malignant metastatic mucosal melanoma of the head and neck with minimal to no adverse effects in comparison to conventional chemotherapy.

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We retrospectively analyzed 35 patients with parotid gland cancer treated in our hospital between 2002 and 2015. There were 25 males and 10 females ranging in age from 31 to 84 years old with the median age of 65. Among the 35 patients, 3 patients （9％）, 5 patients （14％）, 6 patients （17％） and 21 patients （60％） were staged as Ⅰ, Ⅱ, Ⅲ and Ⅳ, respectively. The T stage was T1, T2, T3 and T4 in 3, 7, 7 and 18 patients, respectively. The N stage was N0, N1 and N2 in 20, 6 and 9 patients, respectively. Histopathologically, eleven types of malignancy were observed. The most common pathological type was acinic cell carcinoma in 6 patients. The overall 5-year survival rate of all 35 patients was 52.6％. The overall survival rates for Stage Ⅰ, Ⅱ, Ⅲ and Ⅳ, at 5 years were 100％, 75.0％, 33.3％ and 46.3％, respectively. Univariate analysis showed that significant prognostic factors for overall survival rate were cervical lymph node metastasis, grade, facial nerve resection, lymphatic/vascular invasion, and neural/perineural invasion. Patients with high-risk features are recommended to receive postoperative radiation therapy to improve the therapeutic outcomes.

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We reviewed the clinical data of 18 patients with mucosal malignant melanoma of the nasal/paranasal cavity at our hospital between 2007 and 2016. There were 6 men and 12 women, aged 55-84 years （median: 72）. The clinical TNM classification according to the 7th AJCC/UICC was as follows: T3, 10 cases; T4a, 8 cases; N0, 17 cases; N1, 1 case; M1, 2 cases; Stage Ⅲ, 10 cases; Stage Ⅳa, 6 cases; Stage Ⅳc, 2 cases. The 3-year local control rate （Kaplan-Meier method） was 67％ and the overall survival rate was 80％. The rate of local recurrence was 70％ for patients with complete resection and the rate of recurrence due to skin lesion was 86％. The rate of recurrence of malignant melanoma was very high, thus the extent of resection must be considered case by case.

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It has been reported that neck incision is required to remove an extra-pharyngeal foreign body because it is difficult to detect. Here we report a case with an extra-pharyngeal fish bone, which we could remove transorally using a Sato-type curved laryngoscope.
The patient was a 72-year-old woman who developed swallowing pain after eating a flatfish and visited our hospital on the following day. A flexible endoscopic examination of the pharynx and larynx revealed a slight swelling in the right posterior wall of her hypopharynx. A CT examination showed a linear high density located in the submucosal layer of her hypopharynx at the level of the third cervical vertebra. She was diagnosed as having an extra-pharyngeal fish bone and underwent surgery under general anesthesia. We obtained a wide view of the hypopharynx using a Sato-type curved laryngoscope and incised the hypopharyngeal mucosa on the basis of CT findings. Then, we detected and removed the fish bone. The reasons for successful transoral removal of the extra-pharyngeal foreign body may have been the absence of infection due to the early presentation, the accurate identification of the location by CT examination, and a wide surgical view of the hypopharynx using a Sato-type curved laryngoscope.

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Nerve sheath myxoma was initially reported by Harkin & Reed1） in 1969 as myxoma of the nerve sheath with its feature of abundant myxoid matrix derived from nerve sheaths in the nerve fibers of the peripheral nerves. We experienced a 31-year-old male patient who visited the hospital with the main complaint of a left cervical swelling. We performed intercapsular resection due to suspected left cervical neurinoma derived from the brachial plexus, and made a diagnosis of nerve sheath myxoma based on the results of the histopathologic examination. We report this rare case, with a review of the literature.

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A benign laryngeal tumor such as lipoma can sometimes develop airway stenosis. A 56-year-old woman with symptoms of pharyngeal discomfort and dyspnea in the supine position visited an ENT clinic and was diagnosed as having a laryngeal tumor. Endoscopic examination revealed that a space-occupying lesion between the base of the tongue and the epiglottis extended to the laryngeal cavity. Surgical resection was successfully completed without tracheostomy. General anesthesia was induced by nasal intubation assisted by nasal fiberscopy and transoral tumor retraction. Observation under a distending videolaryngoscope confirmed the tumor was raised from the epiglottis. Dissection of the tumor was achieved by fractional excision, and the tumor was diagnosed histologically as lipoma.

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Amatsu tracheoesophageal shunt （ATES） is one of the primary means of restoring voice after total laryngectomy. ATES can maintain tracheoesophageal speech without a voice prosthesis. A total of 23 patients who underwent ATES operation with total laryngectomy at Hyogo Cancer Center from January 2001 to December 2014 were included, and the rate of voice restoration, speech intelligibility and aspiration were retrospectively analyzed. Speech intelligibility was assessed using the five grades of Taguchi’s criteria, and the aspiration was assessed using the following three groups: （1） none; （2） mild; （3） severe. Of the 23 patients, 18 （78％） succeeded in achieving postoperative tracheoesophageal speech. Of the 18 patients, 13, 1, 2 and 2 patients had Grade 1, Grade 2, Grade 3 and Grade 4 speech intelligibility, respectively. Regarding aspiration, 8 and 2 patients had mild and severe aspiration, respectively. ATES achieved favorable speech intelligibility and low aspiration rate in this study.

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We present a case of noninvasive paranasal aspergillosis with brain abscess during postoperative follow-up of endoscopic sinus surgery. The patient was treated with voriconazole. A 74-year-old woman underwent endoscopic sinus surgery with diagnosis of right orbital syndrome due to paranasal fungal disease. The diagnosis was noninvasive paranasal aspergillosis. Seven months after surgery, image findings showed thickening around the right orbital tip and dura, and brain abscess. Long-term treatment with voriconazole was performed due to invasive paranasal aspergillosis. The brain abscess improved at 9 months. Even if invasive paranasal aspergillosis cannot be confirmed in pathological findings in patients with impaired immune function, if invasive paranasal aspergillosis is suspected from progress, examination findings, images, etc., close observation with images and aggressive treatment by antifungal agent seem to be necessary.

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Intraoperative facial nerve monitoring helps the surgeon to localize the course of the facial nerve, reduce the possibility of its injury during surgery, and assure its anatomical and functional integrity. Here, we report our experience of monitoring the intraoperative facial nerve in a case of giant malignant tumor of the parotid gland. The patient was a fifty-year old woman who had noticed swelling of the left cheek six years ago. When she visited our hospital, the tumor had grown to a size of 29×17×15cm, and she did not have facial nerve paralysis. We used Nerve Integrity Monitoring-Response （NIM） in this parotid surgery, and the facial nerve branches within the substance of the parotid gland were identified in the surgical field by using the NIM system. The tumor was completely removed surgically to preserve the facial nerve. Pathological examination showed salivary duct carcinoma ex pleomorphic adenoma. There has been no recurrence for four years. As it is difficult to find the facial nerve trunk due to the size of the tumor in a case of giant malignant tumor of the parotid gland, the intraoperative NIM nerve monitoring system enables surgeons to identify facial nerve branches and to avoid nerve damage.

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A conduit for peripheral nerve regeneration （Nerbridge®） in cases with disconnection or deficiency of the peripheral nerve was approved in Japan in 2013. The use of Nerbridge has been reported mainly in orthopedic surgery, and its efficacy in trials was 82.8％. We report two cases of lingual nerve reconstruction using Nerbridge. In both cases, the lingual nerve was resected due to submandibular gland cancer. We evaluated the cases by the Semmes-Weinstein monofilaments test. In the 1-year postoperative evaluation, the results were 4.17 Fm （purple） and 4.56 Fm （red）, and the sensory nerve had recovered. There are problems with length restriction and price, but it is one of the effective reconstruction methods for reconstruction of the lingual nerve.

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There remains considerable controversy on the precise criteria for diagnosing IgG4-related diseases. To resolve these problems, we describe and discuss our experience of one case with a solitary mass in the parotid gland which was diagnosed as an IgG4-related disease.
A 57-year-old male patient presented with a mass in the left parotid gland. The pre-operative diagnosis by MRI and fine needle aspiration cytology was a benign tumor of the parotid gland. However, pathological examination after parotidectomy revealed infiltration of IgG4-positive plasma cells. In addition, the level of serum IgG4 was elevated to 515mg/dl. These findings meet the clinical criteria for the diagnosis of an IgG4-related disease. Multicentric Castleman’s disease, which cannot be distinguished on the basis of pathological findings or level of serum IgG4, was ruled out as there were no typical findings of the disease. Taken together, these findings suggest that this parotid gland mass was definitely an IgG4-related disease.

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We performed submucosal autologous fat injections to the pharyngeal orifice of the eustachian tube for a case of patulous eustachian tube in which the symptoms did not improve with conservative treatment. As otitis media with effusion occurred postoperatively, an eardrum ventilation tube was placed. Although hearing ability did not improve, unpleasant subjective symptoms such as amplified volume of own voice and perceiving self-respiratory sounds disappeared. Although surgery is anticipated to improve symptoms in cases of patulous eustachian tube, it is important to deal with the recurrence of symptoms and complications such as otitis media with effusion. We investigated indications and appropriate procedures for surgery to treat patulous eustachian tube and report on our results together with a review of the literature.

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Dermoid cyst of the floor of the mouth is relatively rare and is often difficult to distinguish from ranula. Intra-oral resection of the dermoid cyst is sometimes difficult because of poor visibility. We report a 27-year-old woman with an oral floor cystic mass which had been diagnosed as a ranula at the previous hospital. Magnetic resonance imaging demonstrated a lesion containing multiple uniformly rounded foci. This characteristic finding called “sack of marbles” raised a suspicion of dermoid cyst. We performed intra-oral endoscopic resection with good visualization of the lesion. It was histologically diagnosed as a dermoid cyst. Endoscope-assisted intraoral resection could be useful to treat a cystic mass in the floor of the mouth.

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We present six patients with head and neck osteosarcomas. They ranged in age from 15 to 84 years with a median age of 63.5 years. There were five males and one female. The site of origin was the mandibular bone in four patients, the maxilla in one, and the larynx in one. Five patients were TNM stage ⅡA and one was stage Ⅲ. Histological findings revealed osteoblastic cancers in five patients and chondroblastic in one. All patients underwent surgical resection and adjuvant therapy was performed in five cases. Pathologically complete resections were obtained in five cases; however, only one patient was diagnosed with positive margins in the surgical specimen. In two cases, the cancer recurred, one locally at 2 months and the other by distant metastasis at 12 months. The case of local recurrence was non-responsive to preoperative chemotherapy and was stump-positive upon resection.

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Though schwannomas can arise in any part of the body, those arising in the tongue base are rare. Herein, we report a case of a schwannoma at the tongue base that was completely removed via a transoral approach under general anesthesia. A 42-year-old man was referred to our department because of protrusion of the tongue base, which was detected incidentally during contrast inspection of the digestive tract. We found a submucosal tumor at the tongue base, which occupied more than half of the oropharyngeal cavity. The tumor was diagnosed to be benign based on the results of a rapid intraoperative pathologic examination, after which it was removed via a transoral approach using an FK-WO retractor and Endoeye flex. The final pathological diagnosis was a schwannoma. The patient was discharged from the hospital without any neurologic deficits or postoperative complications. This case indicates that schwannomas should be considered as a possibility in the differential diagnosis of submucosal tumors at the tongue base.

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We report Z-meatoplasty for use during “canal-wall down” procedures to treat patients with cholesteatoma. A skin incision is made along the posterior and inferior conchal borders, along the posterior ear canal meatus to create two deltoidal flaps, an inferiorly based flap of ear canal skin and a posterosuperiorly based flap of conchal skin. The conchal cartilage and underlying soft tissue are excised and the two triangular flaps are transposed and sutured to each other to complete the Z-plasty. The Z-plasty is good for meatoplasty, because it has the effects of elongation and forming a peak to valley. The Z-meatoplasty is relative easy to use, does not make a raw surface, provides easy access to the attic, posterior mesotympanum and mastoid cavity, and is cosmetically acceptable.

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