Every surgeon, wherever they work, needs knowledge of anatomy and surgical skills in their specialty, as well as the techniques necessary to complete a surgery through the proper use of surgical instruments.
There are three main types of surgical skills training: on-the-job training （OnJT）, dry-lab training （DLT）, and wet-lab training; however, OnJT is not always suitable due to healthcare safety, and in disciplines where there are few surgeons, like those who work in the head and neck surgery department, training such as dry-lab training has not progressed sufficiently.
Neck dissection, which is one of the important surgical procedures in head and neck surgery, requires various surgical skills, including handling of scalpels and forceps, knot tying, appropriate use of energy devices, and suture technique, but there are no guidelines on training for safely and effectively acquiring those skills. Moreover, training methods differ depending on the facility. Because it is difficult to teach doctors in training or junior doctors everything through OnJT, we performed surgical skills training for junior doctors using biological models and examined self-assessment of proficiency before and after training to confirm the effectiveness of their training. As a result, this training was significantly effective in improving their surgical skills. Therefore, surgical skills training with biological models is useful in terms of healthcare safety and for improving surgical skills. Our training was approved by an animal experimentation committee at Showa University （Permission number: 08086）.

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Background: The progression of head and neck squamous cell carcinoma （HN-SCC） is sometimes rapid. It is well known that, for a good prognosis, it is critical to avoid a delay in initiating radiation therapy for HN-SCC.
Objectives: We defined the waiting period as the duration between the date of first visit to the medical institution and the date of treatment initiation. Additionally, we determined the impacts of factors affecting the starting period of radiation therapy.
Materials and Methods: The population data were retrospectively sourced from medical charts involving 49 HN-SCC patients with a median waiting period of 38 days who underwent new radiation therapy or chemoradiation therapy at our department from April 1, 2017 to March 31, 2019.
Results: Mainly, the waiting period （38 days） and the duration between a pathologically confirmed diagnosis and the initiation of radiotherapy （26 days） for HN-SCC were both significantly shorter than those found previously in other related studies. When the primary lesion was the hypopharynx, the waiting period for treatment was longer than that of the oropharynx and larynx. Additionally, although there was no statistical difference, the cases first detected in the ENT department were shorter than those first detected in other departments.
Conclusion: The waiting period for HN-SCC was significantly shorter than those found previously in other related studies. The detection and diagnosis of hypopharyngeal cancer tend to be delayed, so careful attention is required. We believe that it is necessary to encourage, through public awareness activities, patients to consult an ENT department when there are symptoms suggestive of head and neck cancer.

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Detection of autofluorescence （AF） from the parathyroid gland （PG） using near-infrared fluorescence imaging （NIFI） is useful for identifying PGs in thyroid and parathyroid surgeries. We measured the AF of 11 PGs from 7 patients using two commercially available NIFIs, pde-neo® （Hamamatsu Photonics） and FLUOBEAM 800® （FLUOPTICS）, and compared their AF intensities and basic characteristics of each device. Both devices could detect the significant AF from PGs with no significant difference between the devices. Given that no differences were found in detection sensitivity between the devices, pde-neo® is useful for ex vivo identification of resected parathyroid glands for auto-transplantation, whereas FLUOBEAM 800® is useful for identifying unnoticed PGs for in situ preservation in the surgical field.

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A clinical study was made of 22 patients with previously untreated submandibular gland carcinomas in our department between 2009 and 2018. Overall three- and five-year survival rates were both 79.4％ and relapse-free three- and five-year survival rates were both 69.8％. All of the cases of recurrence showed distant metastasis.
Six patients had distant metastasis, four patients died of the disease, and two patients were alive with recurrence. Multivariate analysis showed lymph node metastasis was a significant factor for relapse-free survival. Our study suggested that death due to submandibular gland carcinoma occurred mainly due to distant metastasis. New medical treatments need to be developed to improve survival in patients with submandibular gland carcinoma.

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We compared sizes of rhinostomy and success rates of two surgical procedures used for the treatment of nasolacrimal duct obstruction and common canaliculus obstruction. Procedure A, extraductal transillumination-guided endoscopic dacryocystorhinostomy without stenting （EDTI-guided En-DCR-WOS）, was done on 14 eyes （11 patients） between August 2018 and October 2019. A single otorhinolaryngologist performed the surgery alone using the EDTI guide, without the use of fibrin glue and navigation system. Procedure B, conventional En-DCR, was done on 23 eyes （18 patients） between March 2016 and October 2018. An ophthalmologist assisted the ENT surgeon by introducing an intraductal transillumination guide and intubation of lacrimal stent after opening the lacrimal sac into the nasal cavity. Thirteen eyes （93％） out of 14 in group A, and 14 eyes （61％） out of 23 in group B, acquired large, oval-shaped rhinostomies （p＞0.05）. Two eyes in group B needed revision surgery because their symptoms recurred due to obstruction of the rhinostomies. Anatomical success rates were 100％ in group A and 91％ in group B, and functional success rates were 93％ in group A and 87％ in group B （p＞0.05）. The EDTI-guided En-DCR-WOS was thought to be a useful method for primary endoscopic dacryocystorhinostomy in an adult nasolacrimal duct obstruction case without pre-saccal obstruction, with a high success rate and good endonasal findings. This procedure is especially suitable when the otorhinolaryngologist alone performs the surgery.

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The frequency of salivary gland cancer including parotid cancer is about 3-5％ of head and neck cancers, and its histology type is various. The first choice of treatment is surgery, and radiation therapy is added depending on the pathology and malignancy. We retrospectively analyzed 72 patients with primary parotid gland cancer who underwent initial surgical treatment at Nagoya City University Hospital from March 2006 to September 2019. The study group comprised 48 males and 24 females with a median age of 59 years. There were 5 patients in StageⅠ, 25 patients in StageⅡ, 15 patients in StageⅢ, and 27 patients in StageⅣ. Median follow-up was 3.5 years. The 3-year overall survival rate was 87.5％, and the 3-year disease-free survival rate was 69.1％. Postoperative radiotherapy （PORT） was performed for 36 patients. The treatment resulted in relapse in 22 patients and distant metastasis in 17 patients, including 13 salivary duct carcinoma patients. Since distant metastasis was observed in many patients with salivary gland cancer, new treatment strategies need to be developed.

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Objective: We studied distant metastasis in patients with N1a and N1b papillary thyroid carcinoma （PTC） and clarified the significance of lateral neck lymph node metastasis as a risk factor for distant metastasis.
Subjects: Of the 427 patients with PTC who underwent surgical treatment at our hospital, 218 patients with lymph node metastasis were assessed in this study.
Results: The distant metastasis rate was higher when metastases were found at levels Vb or Ⅶ. Based on multivariate analysis, age （≥55 years）, tumor size （≥4cm）, and metastasis to level Ⅴb＋Ⅶ significantly increased the distant metastasis rate, and 88.9％ of the patients in the N1b group showed extranodal extension.
Conclusions: For metastasis to N1b, especially level Vb or Ⅶ, total thyroidectomy with lateral neck dissection should be the first choice for post-operative RAI （radioactive iodine） therapy.

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The main strategies for controlling lymph node metastasis for early tongue cancer in Japan are elective neck dissection or watchful waiting. Elective neck dissection offers significantly better survival, but adversely impacts the patient’s quality of life. We performed a retrospective study of 34 patients with early tongue cancer who underwent partial glossectomy as a primary treatment at the Department of Otolaryngology, St. Marianna University School of Medicine from January 2008 to December 2017. All patients had a partial glossectomy as a primary treatment. Elective neck dissection was performed in 7 of 34 patients at the same time. Local recurrence occurred in 4 of 34 patients （11.8％）. Occult lymph node metastases occurred in 5 of 34 patients （14.7％）. Delayed lymph node metastases occurred in 4 of 27 patients and 2 patients died of recurrent disease. Delayed lymph node metastasis did not occur in 7 patients who underwent elective neck dissection. The 3-year overall survival rate of early tongue cancer was 86.7％. The 3-year disease-specific survival rate was 93.8％.
We could not conclude that pathological depth of invasion （DOI） is a useful predictor for the selection of elective neck dissection. Nevertheless, pathological DOI is a more useful predictor for the selection of elective neck dissection than other clinicopathological evaluations if we can examine clinical DOI in preoperative image diagnosis. In the future, it will be necessary to develop a standardized measurement method for measuring clinical DOI in preoperative image diagnosis using MRI or US.

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We report on our surgical procedure for dorsal septal deviation. The subjects were 10 patients who underwent surgery with a chief complaint of nasal obstruction from January 2018 to December 2019. The surgical procedures are: 1） open septorhinoplasty approach, osteotomy, 2） hemitransfixion approach, folding fracture, and 3） open septorhinoplasty approach, osteotomy and folding fracture. There were two cases of 1）, five cases of 2）, and three cases of 3）. In all cases, nasal obstruction improved and there were no postoperative complications. It is considered that otolaryngologists will need to perform surgical procedures for dorsal septal deviation and open septorhinoplasty.

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Endoscopic transoral surgeries such as transoral robotic surgeries and non-robotic Japanese transoral surgeries including our end-flexible-rigidscopic transoral surgery （E-TOS）, endoscopic laryngopharyngeal surgery （ELPS）, and transoral videolaryngoscopic surgery （TOVS） are performed as minimally invasive local treatment procedures for laryngo-pharyngeal cancers. Transoral closure of the wound surface is difficult because the laryngopharyngeal lumen is deeply located and cannot be directly accessed via the oral cavity. Therefore, defects after transoral laryngo-pharyngeal resection are often left as raw wounds. Postoperative complications such as bleeding, emphysema and fistula formation have been reported to occur in the uncovered method. We introduced a modified technique for covering defects with fibrin glue and polyglycolic acid （PGA） sheets （mMCFP technique） in patients undergoing endoscopic transoral surgeries for laryngopharyngeal cancers. The aim of this study was to retrospectively evaluate the safety of our mMCFP technique. Between June 2013 and September 2019, 112 patients underwent simultaneous E-TOS and wound coverage using our mMCFP technique. There were 83.9% men, and the average age was 65 years old. In this study, regarding the most common primary site and T stage, hypopharyngeal cancers and T2 disease accounted for 66 cases （58.9％） and 70 cases （62.5％）, respectively. Invasive cancer accounted for 81 cases （72.3％）. 110 patients （98.2％） were diagnosed with squamous cell carcinoma. A total of 60.7％ patients underwent simultaneous neck dissection. In 58.0% of patients, the PGA sheets could be observed on the wound surface from 2 to 3 weeks. Other than postoperative bleeding in two patients （1.8％）, no postoperative complications were recorded. The findings of the present study suggest that our mMCFP technique is a safe and simple method for the coverage and repair of mucosal and/or muscle layer defects after endoscopic transoral surgery for laryngopharyngeal cancers.

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We studied the risk factors of tumor spillage from the intraoperative and pathological findings in 25 patients with parotid pleomorphic adenoma. There were 20 patients who had tumor exposure out of the parotid gland during operation, due to tumor exposure all along and contact with the facial nerve. Pathological capsules such as focal absence of the capsule, tumor invasion into the capsule, pseudopod and satellite nodule were identified in 90% of patients with classic and myxoid type tumor, and in 80% of all patients. Fifteen of the patients with tumor exposure were thought to be at risk of tumor spillage. The actual low rate of recurrence suggests that tumor spillage is avoidable by very careful operation.

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The jejunal free flap, which is a luminal organ, is widely used for reconstruction after pharyngolaryngectomy for advanced cancer of the hypopharynx and larynx, and even a free jejunal patch is also used after partial hypopharyngectomy. In this study, from June 2006 to December 2018 in Oita University, we reported six cases of reconstruction using a free jejunal patch for head and neck cancer cases that had a history of radiation therapy in the head and neck region. There were five males and one female, and the average age was 56.3 years old. There were two cases each of hypopharyngeal cancer, oropharyngeal cancer, and laryngeal cancer. Preoperative irradiation as the first-line treatment was excluded. All cases were tumor recurrence cases or metachronous double cancer cases. In all cases, postoperative complications such as postoperative flap necrosis and pharyngocutaneous fistula were not observed. The free jejunal patch is considered to be a useful flap in head and neck reconstruction after irradiation therapy.

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The patient was a 59-year-old man who visited our hospital with right trachelophyma. Tumor biopsy of the base of the tongue revealed squamous cell carcinoma. His condition was diagnosed as oropharyngeal cancer （T1N2bM0：The 7th edition of the UICC）. Before starting the treatment, he refused to visit our hospital. He visited our hospital 8 years and 11 months later because cervical lymph node metastasis was worsening. His condition was diagnosed as oropharyngeal cancer （T3N3M0：The 7th edition of the UICC）, and treatment started 1 month later. Multiple pulmonary metastasis was confirmed another 6 months later, and he died 15 months thereafter.
Untreated head and neck squamous cell carcinoma is considered to have a poor prognosis. However, this case met many of the criteria for a positive prognosis at the first consultation, and so he could survive for a long time without treatment. Taking the rate of tumor growth into account, we considered the prognosis of patients with p16 positive oropharyngeal cancer.

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Although stapes surgery is considered to have better post-operative hearing results than other ossicular reconstructions, some cases need re-surgery without achieving satisfactory hearing. The case was a 7-year-old girl who was diagnosed with congenital stapes fixation, and required multiple stapes surgery on both sides. Since a Teflon wire piston was changed to a Teflon piston and her hearing ability was stabilized, a longer Teflon piston was recommended. In addition, the taste threshold of electrogustometry was normal even after multiple operations, and so it was thought that recovery from tympanic nerve injury caused by ear surgery is better in children than in adults.

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Sinonasal undifferentiated carcinoma （SNUC） is a rare and aggressive malignancy with a propensity for extensive local invasion and poor overall prognosis. Since its rarity has made it difficult to conduct clinical trials, there is no consensus on the optimal management of SNUC. We describe two cases of SNUC （T4bN0M0, stage ⅣA） with skull-base invasions treated with induction chemotherapy （IC） using cisplatin plus etoposide, followed by definitive chemoradiotherapy （CRT） using cisplatin plus etoposide. In case 1, a 63-year-old male patient with a partial response to IC experienced complete response （CR） after CRT. In case 2, a 70-year-old male patient with a stable disease to IC experienced CR after CRT. Four months after initial CRT, a distant metastasis was found in his mandible, but the metastatic lesion had shown CR after CRT using cisplatin plus etoposide. In patients who achieve a favorable response to IC with cisplatin plus etoposide, definitive CRT with cisplatin plus etoposide should result in good local control. In patients who do not achieve a favorable response to IC but cannot choose surgery, definitive CRT might also be a useful option for local advanced SNUC.

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Four patients with non-recurrent inferior laryngeal nerve （NRLIN） were observed during thyroid and parathyroid surgeries. A 67-year-old man with parathyroid adenoma of the right inferior gland, a 70-year-old female with papillary carcinoma （cT1N0M0）, a 65-year-old female with papillary carcinoma （cT4aN0M0） and a 38-year-old male with adenomatous goiter were treated, with resection of parathyroid, right lobectomy, total thyroidectomy, and left lobectomy, respectively. Right NRILN was found in three patients and left NRILN was found in one patient. Preoperative CT showed abnormal running of the subclavian artery in all cases. Out of 190 patients treated by thyroidectomy or parathyroidectomy in the past three years, NRILN was observed in three patients （1.9％） on 151 right sides, and in one patient （0.7％） on 145 left sides. Left NRILN has been reported in only five cases so far, and this case is the sixth case report. Although NRILN is rare, preoperative CT is useful to predict NRILN resulting from abnormal running of the subclavian artery.

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Laryngeal chondrosarcoma is a rare tumor accounting for less than 1％ of primary malignant tumors of the larynx. A male in his 50s had been followed up for 6 years at a previous hospital for a laryngeal tumor that was suspected of being a benign chondroma originating from the cricoid cartilage. He was introduced to our hospital because the size of the tumor had gradually increased and the subglottic space was narrowed. A laryngofissure was performed to identify the tumor location and then the tumor was resected with a safety margin. Since the framework of the larynx was maintained after removing the tumor, open laryngeal preservation surgery was carried out. Histopathological examination showed a diagnosis of Grade I chondrosarcoma. The patient is currently being followed up, and no clear recurrence has been observed for 2 years after the surgery.
For laryngeal chondrosarcoma, laryngeal preservation surgery may be attempted depending on the degree of development and growth of the tumor.

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Piriform sinus fistula （PSF） is an anomaly of embryologic development of the branchial apparatus and sometimes causes acute suppurative thyroiditis. Two cases of piriform sinus fistula recorded in the Fukushima Thyroid Ultrasound Examination （FTUE） are presented.
The patients in cases 1 and 2 were a 14-year-old girl and a 15-year-old girl, respectively. Thyroiditis was observed with right PSF before the FTUE in case 1, while thyroiditis and left PSF were observed after the FTUE in case 2. Both cases underwent complete removal of the sinus tract and showed a favorable course. In the ultrasound examination of FTUE, a hypoechoic tubular lesion that emerged from the posterolateral aspect of the thyroid cartilage and across the thyroid gland and other characteristics that were difficult to distinguish from malignancy were identified in each case.
Generally, ultrasound findings of PSF with thyroiditis include some doubtful characteristics of malignancy. Although other inspections are warranted for diagnosis, a hypoechoic tubular lesion that emerges from the thyroid cartilage and across the thyroid gland should be suspected as a characteristic of PSF.

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Tumoral calcinosis is known as a disease with large periarticular calcified masses typically located at large joints such as the hip, elbow, shoulder, foot, and wrist. We herein describe a rare case of tumoral calcinosis which developed in the deep cervical region. The case was a 48-year-old woman. She had been on hemodialysis for 4 years because of renal insufficiency due to gout. She had developed a growing mass in the right cervical region about 6 months before accompanying numbness and limited range of motion in the right upper extremity. An imaging study revealed a lobular calcified mass of approximately 50mm in the deeper layer of the right sternocleidomastoid muscle and a smaller calcified mass in the left neck. Because the mass in the right side was considered to be causing neurological symptoms, surgical resection was performed and the symptoms disappeared postoperatively. Pathological examination showed calcification and a foreign body granulation reaction of multinucleated giant cells, and the mass was diagnosed as tumoral calcinosis. While medical treatment is generally preferred for tumoral calcinosis, surgical resection might be effective particularly when the mass lesion causes neurological symptoms as in the case reported here. Although cases of tumoral calcinosis developing in the deep cervical region seem to be extremely rare, the possibility should be considered because appropriate surgical intervention could relieve various neurological symptoms affecting the patients.

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A 70-year-old man vomited an amount of blood suddenly at home, and was transported to our hospital by ambulance. As a medical history, 7 years earlier, he had undergone radiation therapy and right neck dissection for the treatment of hypopharyngeal cancer. Four months earlier, due to recurrence of hypopharyngeal cancer, he had undergone total pharyngo-laryngo esophagectomy and reconstruction surgery with free jejunum. At the first visit, the bleeding had already stopped, so we considered that the bleeding had occurred at the mucosa of the transplanted free jejunum. However, 28 hours later, he vomited blood again. We examined his transplanted free jejunum under general anesthesia and diagnosed that the transplanted free jejunum had an ulcer and fistula, and bleeding was due to a ruptured aneurysm of the external carotid artery. The external carotid artery was embolized with endovascular treatment and the bleeding was stopped. Two days after embolization, we performed partial resection of the necrotic free jejunum and reconstruction with a pectoral major myocutaneous flap.

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Acquired hemophilia A is a bleeding disorder characterized by the development of autoantibodies to coagulation factor Ⅷ. Herein, we report a case of acquired hemophilia A in an 81-year-old man that developed after he was treated for hypopharyngeal cancer with combined cetuximab and radiation therapy in 20XX−5. Although there was no recurrence or metastasis of the cancer, the patient experienced bleeding of the buccal mucosa and was diagnosed with acquired hemophilia in 20XX, for which he is currently undergoing treatment.
Acquired hemophilia is thought to be caused by autoimmune disorders, antihypertensive agents, antibiotics such as penicillin-based drugs, skin diseases such as pemphigus, and malignant tumors. Tumors are present in 17％ of patients with acquired hemophilia. Patients who develop acquired hemophilia after treatment for malignancy require more careful follow-up in view of the possibility of recurrence and/or metastasis of cancer. This information should be noted by both physicians and otolaryngologists.

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Benign symmetric lipomatosis （Madelung’s disease） is a rare disease characterized by the occurrence of symmetrical and focal deposition of adipose tissues in the neck, trunk, and limbs. Patients with an accumulation of fats around the larynx and mediastinum develop dysphagia, dysphonia, and sleep apnea syndrome. Madelung’s disease is mainly reported in middle-aged men who have been chronically consuming excessive alcohol. It is comparatively common in the Mediterranean area but rare in Japan. We report three cases of Madelung’s disease with a chief complaint of neck swelling. Case 1 was a 76-year-old man with hoarseness in speech and dysphagia with fat deposits around the larynx. Surgery was considered but due to deterioration of the swallowing function, follow-up was suggested. Though the patient had no further increase in adipose tissue, he died of heart disease two years later. Case 2 was a 61-year-old man with adipose tissue in the retropharyngeal space who had to undergo surgical resection of the adipose tissue in the neck. Case 3 was a 72-year-old man with adipose tissue in the retropharyngeal and parapharyngeal space who underwent a lipectomy of the neck. Both Cases 2 and 3 showed a high degree of satisfaction with esthetics and did not have further recurrence of cervical lipomatosis. In the treatment of this disease, it is necessary to decide on clinical treatments and/or surgical courses taking into consideration the complications of individual cases. It is important to positively consider surgical treatment if patients want to improve their appearance or have functional abnormality such as airway obstruction clearance and dysphagia.

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Pyriform sinus fistulas are usually unilateral, and bilateral cases are rare. We report a case of bilateral pyriform sinus fistulas.
A 22-year-old man who complained of left neck pain had a left neck abscess. Video fluorography revealed a left pyriform sinus fistula. When we used a curved laryngoscope during the operation, we found fistulas in both sides of the pyriform sinus. The curved laryngoscope enabled a wide field of view and confirmed the right fistula that could not be identified by the video fluorography. Only the fistula on the left side was removed surgically; the fistula on the right side was observed. In the future, the use of a curved laryngoscope is expected to increase the number of cases in which fistulas that cannot be identified by video fluorography are recognized; countermeasures need to be investigated.

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Carcinoma cuniculatum （CC） is a subtype of squamous cell carcinoma. Characteristic histological findings include proliferation of stratified squamous epithelium and infiltration of underlying stroma exhibiting a cuniculatum （i.e., rabbit burrow） structure. Although of low malignancy, CC often progresses locally and destroys bone. About 50 cases of CC in the maxilla and oral cavity have been reported worldwide. We describe a case of CC in a 63-year-old woman who previously received a diagnosis of, and underwent surgery for, odontogenic keratocyst （OKC） at another hospital. After surgery, she developed widespread relapse, including intraorbital and nasal bone invasion, for which she sought treatment at our hospital. She underwent extended total maxillectomy, and the final diagnosis was maxillary CC with OKC components.

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Cystic lymphatic malformation develops congenitally in lymphangiogenesis, and is generally detected in children aged two years or less. We report a case of cystic lymphatic malformation in an adult in which OK-432 worked well. A 60-year-old man presented with a tumor in the neck region that had been present at birth. The tumor grew larger after an operation for cervical hernia. He hoped to be treated, since the tumor had been growing quickly since the age of 58. According to the literature, the treatment for cystic lymphatic malformation is either operation or sclerotherapy in consideration of age and location; we selected sclerotherapy. After sclerotherapy, the cystic lymphatic malformation disappeared, and has not reappeared.

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Carcinoma rarely originates in thyroglossal duct cysts. We report a case of papillary carcinoma that originated in a thyroglossal duct cyst. A 42-year-old woman presented with a 5-year history of a slow-growing left-sided anterior neck mass. Physical examination showed a palpable mobile mass with a maximum diameter of 20mm. Ultrasonography revealed fibrous bands extending from the head and tail of the mass, and these fibrous bands were continuous with the hyoid bone and the pyramidal lobe, respectively. Fine-needle aspiration cytology of the mass revealed papillary carcinoma. Thyroid cancer and metastasis were excluded; therefore, we performed the Sistrunk procedure for resection of the tumor together with a central portion of the hyoid bone. Postoperative histopathological examination confirmed papillary carcinoma with negative surgical margin and pre-laryngeal lymph node metastasis. No recurrence was observed at the 12-month postoperative follow-up.

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