A total of 219 patients underwent surgical treatment for thyroid carcinoma in our department between 2008 and 2016; 24 of these patients underwent combined resection of the larynx, trachea, and/or esophagus due to tumor invasion. Thirteen of the 24 cases were examined, excluding undifferentiated carcinoma, CASTLE, and recurrent carcinoma. The tumors invaded the trachea, the trachea and cricoid cartilage, the trachea and esophagus, and the trachea, cricoid and thyroid cartilage in 4, 5, 1, and 3 patients, respectively.
The 3-year survival rate was 72.5％. Five patients relapsed （3 with distant metastases, 1 with a relapse of the contralateral cervical lymph nodes, and 1 with local recurrence）.
The local recurrence was thought to be due to positive surgical margins. Some reports have found no difference in local recurrence between resections with negative surgical margins and those with microscopically positive margins. However, we suggest that sufficient surgical margins are essential for preventing local recurrence after tumor resection for Ex2 cases. Surgical margins must be carefully delineated for intraoperative pathological diagnosis and should take into consideration future QOL, age, past medical and surgical history, swallowing function, and prognosis.

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With the progress of recent surgical devices including endoscopes, endoscopic endonasal surgeries are commonly performed not only for chronic sinusitis but also for benign tumors such as papilloma. Furthermore, endoscopic endonasal surgeries have been employed for sinonasal malignancies, in particular histological types such as olfactory neuroblastoma, with outcomes comparable to those of incisional surgeries.
Radiotherapy and chemotherapy often play a key role in the treatment of sinonasal malignancies of common histological types such as squamous cell carcinoma, adenoid cystic carcinoma, and anaplastic carcinoma. Concurrent chemoradiation therapy （CCRT） or superselective intra-arterial infusion therapy of high-dose cisplatin and concomitant radiotherapy （RADPLAT） is regularly performed for the most common histological type of sinonasal malignancies, squamous cell carcinoma, in some T2 and cases severer than T3. Since August 2012, we have performed endoscopic endonasal surgeries in addition to these procedures, and have obtained excellent outcomes.
Here we report our experience with 15 cases of sinonasal malignancies. These included 5 malignant melanoma, 4 squamous cell carcinoma, 2 metastasis from renal cancer, 1 malignant solitary fibrous tumor, 1 adenocarcinoma, 1 anaplastic carcinoma, and 1 adenoid cystic carcinoma. In seven cases, the patients underwent the operation for residual or recurrent tumors after CCRT or RADPLAT. Endoscopic endonasal surgery was performed in 7 patients as the primary treatment. Three patients underwent endoscopic endonasal skull base surgery with no severe complications. One patient experienced local recurrence and underwent reoperation of endoscopic endonasal surgery without recurrence to date.
We show that the short-term treatment outcome of endoscopic endonasal surgery for sinonasal malignancy is comparable to that of open rhinosurgery such as lateral rhinotomy. No serious intra or postoperative complication was observed, and the duration of hospitalization was shortened compared to that of open rhinosurgery. We conclude that endoscopic endonasal surgery is an effective salvage surgery for the residual disease of high-grade sinonasal malignancy after CCRT or RADPLAT, and that it is also an effective initial treatment with rigorous indication.

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Peripheral lymph fistula （PLF） may improve hearing prognosis with early surgical treatment. From April 2014 to October 2014, we performed endoscopic lymph fistula closure in seven cases suspected of PLF in our hospital. Cochlin-tomoprotein （CTP） was positive in six of the cases. Average hearing level improved by more than 15 dB in five of the six CTP positive cases. Only four cases showed signs of leakage of perilymph fluid during surgery. In endoscopic surgery, it was possible to obtain a good operative field only with an arc-shaped incision of the external ear canal, and it was possible to diagnose leakage of perilymph fluid and to close the fistula with low invasion. CTP is useful because it can objectively diagnose leakage of perilymph fluid.

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We retrospectively studied the clinical features and treatment course in 10 patients with stage T1 and T2 squamous cell carcinoma of the external auditory canal （EAC） who received initial therapy in our hospital. Six patients underwent lateral temporal bone resection （LTBR）, two patients partial resection of EAC, and two patients radiotherapy. The three-year disease-free survival rates of LTBR, partial resection of EAC, and radiotherapy were 83, 50, and 50 percent, respectively. Recurrence was observed in three patients, one from each of the three treatment groups. Radiotherapy was not effective for all of the patients with recurrence, who died due to cancer progressing to the infratemporal fossa. Considering that LTBR was a satisfactory result, removal of the tumor with sufficient safety margin by using LTBR is important for T1 and T2 carcinoma of EAC.

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Deep neck infection can be safely controlled and is well known. On the other hand, descending necrotizing mediastinitis followed by pharyngeal and odontogenic infection is still a life-threatening infection disease. We present six cases who were treated for descending necrotizing mediastinitis, and describe the details of one case who underwent three operations. All cases were diagnosed by CT imaging on the day of admission, and were operated on the same day. Two cases with type Ⅰ received only transcervicotomy, and three cases with type Ⅱa received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoid incision. One case with type Ⅱb needed three operations for a residual abscess. Though tracheotomy was performed in all six cases for the laryngeal edema caused by cervical infection, closure of the tracheal stoma was successful in all cases. Cervical surgical incisions were left open to facilitate drainage, increase tissue exposure to oxygen, and exchange of iodoform gauze. The surgical outcome for each patient was successful. The management of mediastinal infection should be selected according to the classification of the extended degree of infection diagnosed by CT-imaging. Safe and certain management is required in cooperation with thoracic surgeons. Because laryngeal troubles due to cervical infection and multiple operations are not rare, tracheotomy combined with drainage should not be delayed.

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Between 2007 and 2017, we performed lateral temporal bone resection for 10 external auditory canal carcinomas classified as cT1-2 by the Pittsburgh staging system, and examined postoperative complications and treatment outcomes. The clinical stages were T1 in eight cases and T2 in two cases. The histopathological diagnosis was squamous cell carcinoma in all cases. The median follow-up period was 41.6 months. Postoperative histological examinations confirmed margin negative in all cases, thus no case underwent postoperative adjuvant therapy. Postoperative complications were facial nerve paresis, and failure of the sutures and cerebrospinal fluid leakage in one case, respectively. However, both were salvageable and there were no permanent complications. One case with recurrence of neck lymph node underwent neck dissection and was salvaged. In addition, there were no cases of recurrence or distant metastasis. This study revealed that lateral temporal bone resection is safe and a good indicator of external auditory canal carcinoma staged as cT1-2 by the Pittsburgh staging system.

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We reviewed the swallowing function of 64 patients after surgery with advanced oropharyngeal cancer at our hospital between 2007 and 2016. There were 57 men and 7 women, aged 44-88 years （median: 63）. The observation period was 12-96 months （median: 24 months）, p16 positive in 46 cases and p16 negative in 18 cases, and the clinical stage was as follows: Stage Ⅲ, 14 cases; Stage ⅣA, 48 cases; Stage ⅣB, 2 cases. There were 30 cases with postoperative radiation therapy （PORT）. We assessed the swallowing function using the Functional Oral Intake Scale （FOIS） score. High age, p16 negative, resection including root of tongue and PORT were independent factors in poor swallowing function with multivariate analysis and cases with PORT showed no improvement in FOIS score at 12 months.

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Carotid artery rupture is a catastrophic complication in the treatment of head and neck cancer, and is associated with a mortality of 〜40％. We have experienced two cases in which a good prognosis was achieved by performing ligation of the common carotid artery under local anesthesia to patients with a high risk of carotid artery rupture at the terminal stage. In both cases, only the proximal side of the common carotid artery was ligated. The surgery is performed under local anesthesia: the common carotid artery is clamped for 10 minutes during the surgery, and while observing the response of the patient himself, ligation is performed after confirming that there is no appearance of cerebrovascular disorder. CT after surgery showed thrombosis of the common carotid artery and internal carotid artery and the carotid artery did not collapse. Meanwhile, the appearance of cerebrovascular disorder was not observed, and the patients were able to leave the hospital early and live a meaningful life at home.

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Although anaplastic thyroid cancer is highly resistant to any conventional therapy and has an extremely poor prognosis, lenvatinib, a new molecular-targeted drug that became available in 2015, has a significant antitumor effect on this cancer.
We present a case of a 73-year-old woman who was diagnosed with anaplastic thyroid cancer and treated with lenvatinib. The tumor size reduced rapidly for a short time, but esophageal perforation and mediastinitis occurred 57 days after initiation of lenvatinib. Despite the prompt cessation of lenvatinib, carotid artery rupture occurred three days after cessation. The patient underwent carotid artery stenting but died from cerebral infarction due to common carotid occlusion that occurred during the surgery.

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The number of patients attacked by bears has been rising recently because the opportunity to encounter wild bears has increased. Since injury by a bear attack mostly occurs in the head and neck region and can be fatal, adequate and immediate treatment is required.
We report 13 cases of injury inflicted by bears treated in our department and discuss the issues that are important in the treatment of these injuries. All 13 patients thought to have been attacked by black bears （Ursus thibetanus japonicus） suffered from facial contusions. Ten cases had facial bone fractures and four cases went blind in one eye. After the head and neck region, the arms had many injuries and three cases suffered bone fractures in their limbs and the trunk. Three patients developed hemorrhagic shock, however, there were no deaths. Four cases needed local flap reconstruction or skin grafting for defects of facial soft tissue.
It is important to know the features of injuries and to consult a specialist based on the sites and severity of the injuries for the treatment of bear-inflicted injuries.

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Tumors arising in the parapharyngeal space are rare and show various complications because of its complexity. We examined 76 cases of parapharyngeal tumors that had been operated on between 1994 and 2017.
Our review identified more postoperative complications with cases in which tumors were present in the poststyloid parapharyngeal space; especially, vegal complication and Horner syndrome were commonly observed and enduring. When determining the surgical approach for patients with parapharyngeal tumor, it is important to be careful and to consider possible complications.

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Thyroglossal duct cancer is a rare disease, with an incidence rate of 1.6-1.9％ among patients with thyroglossal duct cysts. The most common histological type is papillary carcinoma （80％）. Squamous cell carcinoma accounts for approximately 6％. A 26-year-old male presented to our hospital with a chief complaint of anterior neck swelling. Below the chin, a polycystic mass of 14cm in size and swelling of multiple lymph nodes were observed. Papillary carcinoma was detected using aspiration cytology, and thyroglossal duct cancer was diagnosed based on imaging findings. Tumor resection with total thyroidectomy and bilateral neck dissection was performed using the Sistrunk method. Postoperative histopathology revealed diffuse transition from papillary carcinoma to squamous cell carcinoma in a part of the tumor, and similar pathological findings were observed in some of the metastatic lymph nodes. Squamous cell carcinoma of the head and neck region has been found to have a poor prognosis, and while the transition from papillary carcinoma to squamous cell carcinoma is thought to affect the prognosis, based on the available literature we believe that the prognosis depends on the original histological type of the tumor.

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We experienced a rare case of facial nerve paralysis associated with an isolated styloid process fracture. A 23-year-old man fell onto an iron bar and his right neck was injured. Several hours after the injury, because facial nerve paralysis developed, he was referred to our tertiary care hospital. Physical examination revealed incomplete facial paralysis on the right side; the right stapedial reflex was absent. He was hospitalized and received steroid therapy. However, his paralysis gradually worsened. Detailed CT examination revealed a fracture of the styloid process of the temporal bone along the facial nerve. He underwent surgery six days after the injury. During the surgery, the facial nerve was found to be strained by bone fragments of the styloid process, hyperemic and edematous. The hyperemia and edema of the facial nerve were improved by removing the bone fragments. Postoperatively, the facial nerve paralysis worsened temporarily and then gradually improved. The stapedial reflex was improved, although incomplete paralysis remained.

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The proportion of anaplastic thyroid cancer is only one to two percent of all thyroid cancers. However, multidisciplinary therapy has little effect on the prognosis of anaplastic thyroid cancer. Lenvatinib has been approved in Japan since 2015 as a treatment for patients with unresectable or metastatic thyroid cancer. We administered lenvatinib to nine patients with anaplastic thyroid cancer from October 2015 through January 2017. Two patients were male and seven were female. The mean age of the patients was 74.6 years （with an age range of 54-84）. We investigated the therapeutic effects and adverse events of lenvatinib in these patients with anaplastic thyroid cancer. Six out of the nine patients showed partial response （PR）. One patient survived for more than a year after administration of lenvatinib. In the nine patients administered lenvatinib, the most usual adverse events were hypertension （eight patients）, followed by gastrointestinal symptoms （seven patients）, renal insufficiency （six patients）, thrombocytopenia （four patients）, and fistula formation （three patients）. It is important to continue administering lenvatinib while adjusting the dose depending on the grade of adverse events.

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Anaplastic thyroid cancer（ATC）is one of the most aggressive cancers in humans. Typical therapeutic approaches for malignant neoplasms such as surgery, radiotherapy, chemotherapy and combination therapy have been tried as a radical or palliative therapy for ATC patients, but outcomes are extremely poor. Recently, lenvatinib, which is a multi-targeted tyrosine kinase inhibitor, was approved as a new therapeutic drug for ATC. Here we report a case of ATC treated by lenvatinib.
The patient was an 80-year-old man who developed swelling of the frontal neck. Computed tomography showed that a thyroid tumor, which was diagnosed as anaplastic carcinoma by biopsy, involved the common carotid artery. Lenvatinib was administered for this unresectable case, and the tumor shrank significantly after starting administration. However, four months later, the tumor progressed rapidly and he died due to ATC.
As is generally known, ATC has a very poor prognosis. Lenvatinib could be the treatment of choice for ATC.

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We report herein on an unusually large epidermoid cyst which was removed via an external cervical approach. A 52-year-old female visited a local clinic complaining of a swelling under the tongue which had appeared two months prior to her visit and had caused difficulty in speaking. A CT scan revealed a mass in the floor of the mouth and she was subsequently referred to our department. Our examination revealed in addition to the swelling of the floor of the mouth, the presence of a swelling of the mental region. An ultrasound scan revealed a large cystic mass at the midline of the mental region. A CT scan revealed a shadow from the mental region to the base of the tongue, while an MRI revealed an internal macular cystic tumor which had a membrane with contrast enhancement located cephalad to the mylohyoid muscle. Fine needle aspiration of the mass revealed the presence of viscous yellowish-white content. Surgery was performed and the cyst was removed by blunt dissection along the cyst wall. The histopathology examination determined that the mass was an epidermoid cyst.

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[in Japanese]

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In thyroid surgery, is important to identify and preserve the recurrent nerve. We performed continuous intraoperative neuromonitoring of the vagus and recurrent laryngeal nerve with the aim of reducing the risk of recurrent nerve palsy. We reviewed six cases of thyroid cancer. The pathological diagnosis of these tumors was papillary carcinoma （five cases） and undifferentiated carcinoma （one case）. Two patients were male and four were female. The mean age of the patients was 60.2 years （with an age range of 40-83）. Total thyroidectomy was performed in five cases, and right thyroidectomy was performed in one case. The results of postoperative laryngologic findings and intraoperative evaluation were consistent, suggesting that the reliability of CIONM was high. Particularly, when an immature doctor performs the thyroid surgery, CIONM is thought to be useful for protecting the recurrent laryngeal nerve.

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[in Japanese]

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Misplacement of the electrode array in the internal auditory canal can happen in cases of modiolus defect type inner ear malformation such as Incomplete Partition type Ⅲ （IP-Ⅲ）, which is X-linked deafness due to POU3F4 gene mutation, and common cavity cases where the internal auditory canals are widely opened. We perform fluoroscope-assisted operation to prevent electrode array misplacement. Fluoroscopy is an imaging technique that uses C-arm to obtain real-time moving images of the interior electrode. The anesthesia machine is placed on the contralateral side of the foot of the bed and the operation microscope at the head of the bed. The C-arm is placed out of the way between the anesthesia machine and the operation microscope. With this arrangement, we can perform the operation almost as usual. Because of radiation exposure, the fluoroscope beam should be narrowed and centered to see through only the temporal bone and avoid orbit penetration. It is difficult for the surgeon to confirm fluoroscope monitoring during electrode insertion, so an experienced monitoring assistant should guide the surgeon to insert the electrode in the right place.
Four patients, 1 IP-Ⅲ （13-year-old girl） and 3 common cavities （1-year-old boy, 3-year-old girl, 5-year-old girl）, underwent cochlear implantation with intraoperative fluoroscopic assistance. In the IP-Ⅲ case, gushing happened and the electrode misplacement into the internal auditory canal was confirmed by fluoroscopy at the first time. Immediately, we were able to replace the electrode in the correction location of the cochlea. In the three cases of common cavity, there was no gushing and the electrode could be placed in a good position inside the inner ear from the beginning under fluoroscopy. Fluoroscopically assisted cochlear implantation is an easy and effective technique that results in improved outcomes for cochlear implant patients with modiolus defect type inner ear deformities.

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