[in Japanese]

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[in Japanese]

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[in Japanese]

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For the treatment of blowout fractures, it is important to select an appropriate treatment method considering whether or not the fracture is classified as an emergency. This depends on the presence or absence of incarceration and strangulation of the extraocular muscles and restriction of the orbital contents. However, there is no clear indicator of the severity of the blowout fracture. Therefore, various treatment options have been often discussed, including the surgical method.
We have been getting good results by adopting a combination of the transantral and transorbital approaches for the operation of blowout fractures since 2006. We suggest the usefulness of the combined approach with our new severity assessment by analyzing the patients who have undergone the approach in the last two decades at Fukui University Hospital.

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Due to an increasing number of patients with recurrent or metastatic head and neck cancer receiving long-term chemotherapy, the demand for a safe vascular access device（VAD） is increasing. We analyzed the safety of VADs including a peripherally inserted central venous catheter（PICC） and upper arm port in outpatients receiving chemotherapy. Thirteen cases in the upper arm port group and 27 cases in the PICC group were examined. There were no significant differences in patient background and treatment between the upper arm port and PICC groups. The complication rate was significantly lower in the upper arm port group（0％, 0/1000 catheter days） than in the PICC group（30％, 1.8/1,000 catheter days）（p ＝ 0.037）. The complications of the PICC were four cases of catheter occlusion, two cases of thrombosis, one case of catheter-related bloodstream infection, and one case of accidental removal. The upper arm port is a safe VAD, and it is probably useful for long-term chemotherapy in patients with recurrent or metastatic head and neck cancer.

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Between April 2007 and March 2017, 36 patients （32 males, 4 females; average age, 63.8）with inverted papilloma （IP）in the nasal and paranasal sinus were treated. There were 6 patients in Krouse stage T1, 7 in T2, 20 in T3, and 3 in T4 （2 had malignant IP）. All T1 and T2 cases were treated by endoscopic surgery, and T3 and T4 cases were treated by either endoscopic surgery or lateral rhinotomy, or both. The observation period was 13-84 months and the recurrence rate was 19%. The aim of treating IP surgically is complete tumor resection, and it is important to follow up using rhino-fiberoscopy, CT, or MRI to detect early recurrence of IP.

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We retrospectively analyzed 42 patients with T2N0 laryngeal squamous cell carcinoma treated in our hospital between 2002 and 2017. There were 39 males and 3 females ranging in age from 49 to 89 years old with the median age of 68. Among the 42 patients, 6（14.3％）patients, 32（76.2％）patients and 4（9.5％）patients were classified into supraglottic, glottic and subglottic, respectively. Among the 32 glottic cancer patients, there were 20（62.5％）patients with anterior commissure invasion and 12（37.5％）patients without it. The overall and disease-specific survival rates were 95.2％ and 97.6％, respectively. The 3-year laryngeal preservation rate of all 42 patients was 76.2％. The 3-year laryngeal preservation rate was 69.0％ in the 29 patients who received radiation therapy alone, and 92.3％ in the 13 patients who received chemoradiotherapy. There was no significant difference between the radiation-alone group and the chemoradiation group. A clinical trial is needed to assess the effects of chemoradiotherapy on T2N0 laryngeal squamous cell carcinoma.

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The tolerability of cisplatin （CDDP） was retrospectively examined in 87 patients who received CDDP with concurrent chemoradiotherapy from May 2015 to July 2018. The CDDP doses were 80mg/m² （80mg group） every 3 weeks until 2016 and 100mg/m² （100mg group） every 3 weeks after January 2017. The 87 patients included 63 in the 80mg group and 24 in the 100mg group; 61.9％ and 70.8％ of patients received the full dose （240mg/m² and 300mg/m²）, respectively. Grade 3 or worse adverse events were reported in 52.4％ and 70.8％ in the 80mg group and the 100mg group, respectively. The percentage of patients who received 200mg/m² or more, which is the clinical recommended dose, was 68.3％ and 91.7％ of patients in the 80mg group and 100mg group, respectively. Chemoradiotherapy with CDDP 100mg/m² would be a well-tolerated, high-dose treatment in Japan.

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We studied the risk factors of tumor spillage from the intraoperative and pathological findings in 20 patients with parotid pleomorphic adenoma, who underwent primary operation by our method. There were 18 patients who had tumor exposure out of the parotid gland during operation, due to tumor exposure all along, contact of the facial nerve, or operative manipulation. There were 17 patients with pathological capsules, including focal absence of the capsule, tumor invasion into the capsule and pseudopod/satellite nodule. In regard to histologic subtypes, focal absence of the capsule and pseudopod/satellite nodule were frequent in the myxoid-type tumors and tumor invasion into the capsule was frequent in the classic-type tumors. The facts of highly frequent tumor exposure and incomplete capsule in spite of low rate of recurrence after pleomorphic adenoma operation suggest a relatively low risk of tumor spillage during ablation of the exposed tumor surface. We also consider that our operation is a permissible method of pleomorphic adenoma surgery.

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A retrospective study was conducted to evaluate the clinical outcomes of 11 patients with advanced squamous cell carcinoma of the maxillary sinus in our hospital between April 2012 and January 2016. Three patients had T3 disease, 4 patients had T4a and 4 had T4b. Seven patients underwent surgical resection. Six patients were treated with total maxillectomy and 1 with partial maxillectomy. Four patients who had microscopically involved resection margins and/or were extranodal extension-positive underwent postoperative chemoradiation therapy. The 5-year overall survival rates were 70％ in T3 and 50％ in T4a. Three patients with T4b underwent CCRT. Two were alive with no evidence of disease.

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Bilateral recurrent laryngeal nerve paralysis is a rare condition which occurs due to aggressive thyroid or esophageal cancers, and as a postoperative complication of these diseases. In cases with bilateral recurrent laryngeal nerve paralysis, prompt rescue for the severe impairment of respiration is required, and treatments to widen the airway at the glottis level are controverted. Though the fixation of bilateral vocal folds at the intermediate portion is rare, aspiration with hoarseness is serious. A 35-year-old female underwent surgery for thymus cancer, and suffered from severe aspiration postoperatively. Her aspiration was improved by type I thyroplasty at the left vocal fold, and more favorable swallowing and voice quality were gained by subsequent laryngeal reinnervation at the contralateral fold. Though the treatments for bilateral recurrent laryngeal nerve paralysis are controversial, this technique should be an option for the acquisition of more favorable swallowing and voice.

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Intracranial complications of rhinosinusitis are still considered a life-threatening disease. We report the case of a 13-year-old boy with acute rhinosinusitis. We administered antibiotics during hospitalization. His symptoms and blood test findings improved, and he was discharged from the hospital on the seventh day. On the twelfth day after discharge, he developed a brain abscess and extradural abscess as intracranial complications, and was hospitalized for emergency neurosurgery. Endoscopic sinus surgery was performed with debridement of the brain abscess and extradural abscess via craniotomy and antibiotic therapy. He was discharged home from the hospital without neurological sequelae. Intracranial complications of rhinosinusitis must be carefully assessed with diagnostic imaging and surgical treatment such as endoscopic sinus surgery and neurosurgical procedures.

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Antineutrophil cytoplasmic antibody （ANCA）-associated vasculitis is characterized by inflammation of the vascular wall and the presence of ANCA. We report our experience with a patient with this disease who did not receive diagnostic therapy and had an adverse outcome. A 78-year-old woman presented with refractory otitis media, and based on its clinical course, she was diagnosed as having otitis media with ANCA-associated vasculitis. Subsequent transbronchial biopsy and middle ear biopsy failed to provide a pathologic diagnosis. While she was left untreated, her condition rapidly deteriorated. The treatment of this systemic disease requires the assessment of general physical condition. Although pathologic examination is important, physicians should remember that clear results are rarely obtained. The difficulty of pathologic diagnosis and the importance of diagnostic therapy are discussed based on the present case.

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It is known that cancer develops in about 1〜2% of thyroglossal duct cysts, and in many cases onset occurs before menopause. Also, there have been no reports of cases in Japan where distant metastasis has occurred. We report a case of thyroglossal duct carcinoma with bone metastasis in a late-elderly person. An 89-year-old male underwent tumor resection by the Sistrunk method and right cervical dissection, laryngeal elevation and tracheotomy for a 55-mm large anterior cervical tumor and right cervical lymph node metastasis. He was diagnosed with left cervical lymph node metastasis and microcancer in the thyroid right lobe after 6 months and underwent left cervical dissection and thyroid right lobectomy.
Since right femoral bone metastasis appeared after surgery, he received irradiation and continued to take denosumab. Thyroglossal duct carcinoma also causes bone metastasis as well as thyroid cancer. Also, in the case of onset in the elderly, it is necessary to select therapy in consideration of comorbidities and swallowing functions.

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Undifferentiated pleomorphic sarcoma, which used to be called malignant fibrous histiocytoma, is a tumor of mesenchymal origin and composed of several types of cells including fibroblasts, histiocyte-like cells, atypical giant cells, etc. Undifferentiated pleomorphic sarcoma is a relatively rare disease in the head and neck, especially in the larynx. This report describes an 86-year-old male patient with undifferentiated pleomorphic sarcoma of the primary vocal cord arising during follow-up of vocal cord dysplasia. No recurrence is observed one and a half years after resection of the tumor by laryngeal microsurgery and postoperative radiotherapy.

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We experienced a case of subglottic stenosis that developed after intubation of a double-lumen tube （DLT）. An 81-year-old female patient presented with the chief complaint of dyspnea and hoarseness on the second day after surgery for lung cancer. Endoscopic examination showed web-like stenosis in the subglottic region, and we diagnosed subglottic stenosis. We took a wait-and-see approach after tracheostomy. The airway became completely obstructed on the third postoperative day, subglottic stenosis started to improve from the belly side on the fourth day, and it healed on the ninth day.
Six cases including this case in which subglottic stenosis developed after intubation of DLT have been reported in Japan. All 6 cases had lung cancer, and there were common characteristics of female, short stature and elderly. Subglottic stenosis after DLT intubation has been diagnosed within 3 days after surgery, so when DLT is intubated to patients with these characteristics, it is considered that special attention is required about 3 days after surgery.

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In thyroid and parathyroid surgery, the treatment of recurrent nerve is important, and in order to prevent nerve damage during surgery, it is necessary to be careful of its running route.
There are several subtypes of running route of recurrent nerve, and the non-recurrent inferior laryngeal nerve （NRILN） is a subtype that must not be overlooked. The patient was a 52-year-old male suffering from hoarseness. Left recurrent nerve palsy was seen, and surgery was performed due to a diagnosis of bilateral cervical lymph node metastasis of thyroid papillary carcinoma. During surgery, the right lower laryngeal nerve branched directly from the vagus nerve and it was confirmed that it flowed into the larynx. Post-surgically, we checked the pre-operative cervico-computed tomography scan again and noticed an abnormality of the right subclavian artery, and NRILN was suggested. When an abnormality in the blood vessel branching morphology is seen, surgical operation should be carried out carefully, considering the possible existence of NRILN.

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We report a case of severe dysphagia treated by central-part laryngectomy （CPL） under local anesthesia. An 89-year-old woman presented with a chief complaint of progressive dysphagia. In July X-1, she had undergone intubation and tracheotomy for CO₂ narcosis. Subsequently, she was hospitalized three times owing to aspiration pneumonia. She was transferred to our hospital, and expressed a desire for oral intake despite her progressive dysphagia. A videofluoroscopic swallowing study revealed that her upper esophageal sphincter was completely stenosed. We expected that oral intake would be possible after typical surgical intervention for intractable aspiration, such as total laryngectomy or larynx-trachea separation surgery.
After discussion with an anesthesiologist and pulmonologist, we concluded that general anesthesia was prohibitively risky for her owing to her ventilator dependence, hypercapnia, and advanced age. We therefore performed an operation under local anesthesia. Continuous intravenous infusion of pentazocine and hydroxyzine was used for sedation, and local anesthesia was achieved using subcutaneous injection of lidocaine with 1％ epinephrine. We then successfully performed typical CPL and reconstructed her tracheostoma at the height of the first tracheal ring. Postoperatively, the patient recovered well without major complications, and she became able to ingest food orally and completely.
We conclude that for patients whose comorbid conditions preclude general anesthesia, CPL under local anesthesia alone can be considered.

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For the treatment of a large number of superficial multiple pharyngeal cancers, treatment options that also take into consideration laryngeal function and quality of life after treatment are desired. We report on two-stage transoral excision of simultaneous multiple pharyngeal superficial cancers arising in the bilateral piriform recess. The case was a 70-year-old man with a history of alcoholic cirrhosis. Course of treatment: Partial pharyngectomy from the broader right-side tumor was performed. Two months later, the left tumor was resected. In all cases, local injection of triamcinolone acetonide （TA） was performed after excision, and no postoperative pharyngeal stenosis was observed. Results: The thickness of the tumor was 150μm on the right side and 1,200μm on the left side. Evaluation of tumor blood vessels according to preoperative esophagus superficial esophagus enlargement endoscopic classification, Type B1 on the right side and Type B2 on the left side were considered to be useful for estimation of tumor invasion depth.

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Verrucous carcinoma（VC）is a low-grade cancer characterized by slow growth and weak invasion compared to squamous cell carcinoma. In the head and neck region, it often occurs in the oral cavity and larynx. It is rare at about 1％ in nasal sinus tumors.
The present case was a 77-year-old man. He was admitted to our hospital with nasal congestion due to a left nasal cavity tumor. He had become aware of this tumor 10 years ago. A biopsy of the tumor was performed, and the pathological result was VC. We diagnosed cT3N0M0，Stage Ⅲ and performed the operation. Although a lateral rhinotomy approach was also considered, the operation space was secured by removing the septal cartilage, vomer, and ethmoid, and the tumor could be removed　endoscopically. There is no consensus on the use of chemoradiotherapy for VC. Surgical resection is considered the first choice because there are reports of anaplastic change by irradiation.

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The UICC/AJCC 8th edition TNM classification was revised in 2017, requiring histological examination for the presence or absence of HPV and EBV for a diagnosis of cervical lymph node metastasis from an unknown primary site. We retrospectively analyzed 4 patients with cervical lymph node metastasis from an unknown primary site who visited our hospital from November 1, 2017 to June 30, 2018. We performed tissue sampling with CNB and examined p16 （immunostaining） and EBER-ISH. In all cases, CNB under local anesthesia was possible without complications such as bleeding and airway narrowing. As a result of pathological examination of the obtained tissue, evaluation of p16, EBER-ISH was possible. In conclusion, it was possible to investigate HPV and EBV-related cancers by CNB in cervical lymph node metastasis from an unknown primary site, and it was considered to be useful as a tissue sampling method before treatment.

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In deep cervical abscesses with obesity, it is often difficult to perform tracheostomy and manage tracheal cannulas. In this study of two cases of deep cervical abscess with obesity, the airway was secured by hybrid tracheostomy, combining surgical tracheostomy and percutaneous tracheostomy. In these cases, anatomical landmarks, such as cricoid cartilage and thyroid notch, were identifiable and no infection was found at the tracheostomy. No complications were observed in either of the cases, and the tracheostoma was closed after a short period. Hybrid tracheostomy is considered useful for short-term securing of the airway in obese patients.

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Since accessory parotid carcinomas are rare, the surgical approach for this type of tumor is controversial. We report a case of accessory parotid carcinoma that was excised using an intraoral approach. An 83-year-old man was referred to our department for a left cheek mass. Preoperative cytology showed a suspected benign tumor. Since we could push the tumor medially beyond the anterior edge of the masseter muscle, we were able to easily dissect the tumor intraorally without any postoperative complications. However, the postoperative pathology revealed the mass to be adenocarcinoma. The intraoral approach for resecting accessory parotid tumors is cosmetically superior to the skin incision approach. This approach may be an option for accessory parotid tumor resections.

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