In November 2018, the da Vinci Surgical System was approved under the Pharmaceutical and Medical Device Act for the head and neck region, and in February 2019, the TORS training program was announced with the approval of the Japan Head and Neck Surgery Society. The training program led by the academic society can reduce differences in technique of TORS and can be carried out more safely and reliably. A questionnaire survey was conducted to determine whether pre-training endoscopic laryngopharyngeal surgery had an effect on the learning curve. In this paper, we report on the initial stage of this program.
Observation of the skull base bones and cadaver dissection by a nasal endoscope was performed to visualize the endoscopic anatomy of the auditory tube and the foramen lacerum. The foramen lacerum is an irregular-shaped space formed by the sphenoid, temporal, and occipital bones. After removing the posterior wall of the maxillary sinus, the maxillary artery and its branches were exposed. By removing the periosteum of the anterior wall of the sphenoid bone, the opening of the pterygoid canal was visualized. By drilling the pterygoid process and its medial and lateral plate, the cartilaginous part of the auditory tube was exposed. This cartilage is firmly attached to the groove for this cartilage and the fibrous cartilage of the foramen lacerum. To avoid damaging the internal carotid artery and the cavernous sinus, surgeons should maintain manipulation below the pterygoid canal and foramen lacerum.
Chyle leak/lymphorrhea is a complication that can have serious consequences due to delayed wound healing and wound infection, and requires learning how to avoid it. In this educational panel discussion, I talked about necessary surgical techniques and troubleshooting.
Injury must be prevented beforehand, and it is necessary to know the anatomy of the lymphatic system and thoracic duct. The two-bite method, a preventive surgical technique to prevent thoracic duct injury, was also described.
As a surgical treatment for the onset of chyle leak, a method of ligating the thoracic duct of the upper mediastinum by operating from the neck was described. This is a method to identify the thoracic duct using the inside of the common carotid artery, thoracic entrance and posterior esophagus as a guide.
Patient safety has attracted increasing attention in the context of improving the quality of healthcare. Measures to ensure safety have been introduced one after another during the past decade. We will learn in the lecture how these specific measures fit into the entire framework of improving quality and safety. It is notable that adverse event reporting and learning systems at all levels are drawing the interest of the global community through various initiatives. Through working at the Japan Council for Quality Health Care （JQ） and the International Society for Quality in Healthcare （ISQua）, I have learned that patient safety is a huge focus not only in Japan but also worldwide. The global agenda for quality and safety will be discussed.
Objective: To investigate the treatment outcomes of patients with T3 laryngeal cancer at a single institution. Methods: This retrospective study included 35 patients who were treated at our institution from April 2007 to March 2019. Results: The three-year overall survival （OS） and disease specific survival （DSS） rates were 74％ and 84％, respectively. Eighteen patients underwent laryngectomy （surgery group）, while 17 underwent radiotherapy （RT group） （chemoradiotherapy with cisplatin: 14, bio-radiotherapy with cetuximab: 1, radiotherapy alone: 2）. Although there was no difference in OS between the two groups, the RT group was better in DSS, regional control, and distant metastasis-free survival rates compared to the surgery group, while the surgery group was better in local control rate than the RT group. Analysis of the patient characteristics revealed that the surgery group was significantly older and had N2 status more frequently. The three-year survival rates with functional larynx preservation were 13％ for all the patients and 27％ for the RT group. The cumulative cisplatin dose was more than 200mg/m2 only in 2 of 13 cases who were treated with chemoradiotherapy. Conclusions: There was a significant selection bias for the treatment. Improvement of the larynx preservation rate is warranted, for which the cumulative cisplatin dose administered during chemoradiotherapy should be over 200mg/m2 as the previous study reported.
We examined the usefulness of dynamic study by contrast-enhanced MRI, and the contribution of dynamic study in addition to fine needle aspiration cytology （FNAC） to the accuracy of preoperative diagnosis of parotid tumors. We retrospectively reviewed 61 patients with parotid gland surgery who underwent FNAC and contrast-enhanced MRI before surgery. In the evaluation of the dynamic study, a time-signal intensity curve （TSI curve） was calculated and evaluated. The sensitivity, specificity, and accu-racy of FNAC were 33％, 100％, 89％, respectively. On the other hand, when the A, B, and D types were evaluated as benign and the C type as malignant in the TSI curve, the sensitivity, specificity, and accuracy of the dynamic study were 58％, 98％, 90％, respectively. All of the patients who were evaluated as malignant on FNAC were type C on the TSI curve, so it is considered that adding dynamic study to FNAC increases the accuracy of preoperative diagnosis compared to FNAC alone.
When analyzing the survival rate of hypopharyngeal cancer, a higher rate than the true survival rate may be calculated if many patients cannot visit a hospital due to death. The active follow-up type （AFU） that involves contact with the patient and his/her family or physician to ascertain vital status in addition to medical records can calculate the survival rate with a higher accuracy than the passive follow-up type （PFU） that involves obtaining medical records only. In 2005-2014, we investigated 219 patients with hypopharyngeal cancer who received curative-intent treatment and analyzed the overall survival and censored cases at 5 years. The 5-year overall survival rate that was analyzed by AFU was 44.2％ and the 9-year overall survival rate was 31.3％. The 5-year overall survival rate by PFU was 46.6％ and the 9-year overall survival rate was 37.5％. PFU tended to have a higher survival rate with no significant difference. There was one censored case in AFU and 17 in PFU. The number of censored cases of AFU decreased, and we thus considered that AFU could calculate survival rate with higher accuracy than PFU.
Deep neck abscess is a serious and life-threatening disease, sometimes requiring surgical drainage multiple times. The aim of this study was to analyze the indications for repeated surgical drainage in patients with deep neck abscesses. A retrospective review was conducted of 45 patients who were diagnosed as having deep neck abscesses and underwent surgical drainage in the Department of Otolaryngology at Kobe City Medical Center General Hospital from 2012 to 2019. The 45 patients were divided into two groups: the group which underwent re-operation （re-operation group, n＝11） and the group which underwent surgery just once and were cured （good response group, n＝34）. Their age, sex, results of blood test, bacteriology, site of abscess, radiology and treatment contents were evaluated, and were compared between the two groups. The re-operation group had a significantly higher serum CRP （26.29 vs 12.57, p＝0.001）, free air in the deep neck space on computed tomography more often （45％ vs 11％, p＝0.028）, mediastinitis more often （63％ vs 14％, p＝0.003） and a higher detection rate of Streptococcus milleri group bacteria （63％ vs 26％, p＝0.035） compared to the good response group. In the re-operation group, the following factors tended to occur more frequently: polymicrobial infections （63％ vs 35％, p＝0.091）, abscess in visceral space （64％ vs 32％, p＝0.069） or retropharyngeal space （55％ vs 24％, p＝0.062）, and initial antibiotic treatment by meropenem and vancomycin （36％ vs 9％, p＝0.09）. We concluded that more sufficient and aggressive drainage, such as prophylactic opening of spaces which lead to the mediastinum （visceral space, retropharyngeal space, vascular space） in addition to the space where abscesses exist, may be necessary in treating deep neck abscesses with the factors previously listed.
Juvenile angiofibroma （JA） is a histologically benign tumor that commonly develops in adolescent males. The primary symptoms of JA are nasal obstruction and recurrent nasal bleeding. However, the symptoms may vary depending on the extent of the disease. JA grows osteoclastically and invasively. Thus, depending on the direction of progress of JA, some cases may require treatment approaches based on complete extraction, which are usually used for malignant tumors. In this case, the severity of bleeding could be significantly reduced through preoperative vascular embolization, performing surgery immediately after vascular embolization, and clipping the intraoperative jaw artery. Including this case, we present a total of 13 cases that were reported in Japan in recent years. We also include the stage classification of JA and the selection of surgical procedure for all these cases.
We report a surgical case of pleomorphic adenoma derived from the parotid gland in which the external carotid artery was running in the superficial layer of the digastric muscle. The case was a 39-year-old woman. Surgery was performed with a diagnosis of right parotid pleomorphic adenoma. During the search for the digastric muscle, an external carotid artery was found in the superficial layer of this muscle. The artery was preserved, and the tumor was resected with no complications. The running of the external carotid artery is classified into type Ⅰ to Ⅳ, and this case was type Ⅳ. Its frequency of appearance is extremely low at 0.25％. In parotid gland surgery, it is generally considered that there is no structure that should be preserved in the superficial layer of the digastric muscle. Even though this running abnormality is rare, serious complications such as massive hemorrhage or facial palsy could occur due to hemostatic operation. It may be desirable to check the running of the important blood vessels by preoperative imaging.
In the case of piriform sinus fistula, it is sometimes difficult to identify the fistula opening on the pharynx side by conventional endoscopic inspection. We report a case in which the modified Killian （MK） method was useful for identifying the fistula opening. A 55-year-old woman had undergone left hemithyroidectomy for left piriform sinus fistula. Twenty years later, she showed left anterior neck swelling which was suspected to be a recurrence of the piriform sinus fistula. The fistula opening of the pharynx could be identified by the MK method, but not by endoscopy in the normal position. Under general anesthesia, the fistula opening was successfully closed by an oral approach. There has been no recurrence until 1 year 4 months after the surgery. The MK method is useful for identifying the fistula opening of the pharynx even in the case of recurrent piriform sinus fistula.
We performed combination surgery with right superior lobectomy of the lung under thoracotomy and trans-cervical tumorectomy for a relative large thyroid tumor for a patient with lung cancer. The patient was a 70-year-old man with the chief complaint of cervical pressure. CT scan revealed lung cancer and thyroid tumor, and it was clarified that his complaint was caused by pressure due to a goiter. Therefore, combination surgery with lung lobectomy and thyroid tumorectomy was chosen. The thyroid tumor was able to be removed through the neck in spite of progression forward to the upper mediastinum. At the same time, right superior lung lobectomy, mediastinal lymph node dissection, and 4th-6th rib bone resection under thoracotomy were performed. Tracheostomy was not performed. Complications such as swallowing disorder or phonation disturbance did not occur postoperatively. According to the pathological diagnosis, the lung cancer was squamous cell carcinoma and the thyroid tumor was adenomatous goiter. Usually, combination surgery of the neck and thorax, especially tracheostomy, is not performed because of the high ratio of complications such as mediastinitis or thoracic emphysema. In this case, cervical pressure was applied to the goiter and the inferior edge of the goiter was related to the lung cancer. These were major problems, because the inferior edge of the goiter was involved in the area of lung lobectomy, and it was feared that the goiter could not be removed by the trans-cervical approach after lobectomy, due to postoperative adhesion. For this reason, we decided to perform combination surgery, and obtained good results. It is thought that the choice of long-term intubation to regulate the airway, instead of tracheostomy, prevented complications this time. On the other hand, the goiter was able to be removed by a trans-cervical approach only because the inferior edge of the goiter was located at the superior line of the aorta.
Mixed medullary and follicular thyroid carcinoma （MMFTC） is a rare type of thyroid cancer that shows morphological and immunophenotypical evidence of the coexistence of follicular and parafollicular cell-derived tumor populations within the same lesion. Here, we report the case of a MMFTC patient with mixed lymph node metastases. The patient was a 67-year-old man with no positive history. He had palpable masses on both thyroid lobes and swelling of multiple left neck lymph nodes and several superior mediastinal lymph nodes. Preoperative fine-needle aspiration of each region did not suggest a diagnosis of MMFTC. He underwent total thyroidectomy and left neck lymph node dissection. The left lobe nodule contained MMFTC, the right lobe nodule contained medullary carcinoma, and multiple neck lymph nodes contained medullary carcinoma, papillary carcinoma, and MMFTC. FDG-PET was useful for recognizing the preoperative region associated with the primary MMFTC and its metastases. The serum levels of thyroglobulin, calcitonin, and CEA normalized postoperatively. The patient’s condition has been healthy and there are no signs of recurrence four years after surgical treatment alone.
Follicular dendritic cell sarcoma （FDCS） is a rare neoplasm arising from follicular dendritic cells, which are antigen-presenting cells in the lymphoid follicles. Herein, we report a case of tonsillar FDCS of a 74-year-old woman with the complaint of an asymptomatic tonsillar tumor. The biopsy revealed the histopathological diagnosis as FDCS. We treated the case with radical tonsillectomy by TOVS. The resection margin was negative and adjuvant therapy was not indicated. At the 6-month follow-up after the operation, the patient showed no sign of disease recurrence and the post-operative function was satisfactory. We discuss the treatment strategy for FDCS.
We use a device for oral surgery （tongue, gingiva, cheek, oral floor）, transoral pharyngo-laryngo surgery, endoscopic sinus surgery, and transcanal endoscopic ear surgery. The device has a very thin hand piece, enabling the treatment of narrow spaces （nasal cavity, ear canal）. In endoscopic surgery, we use a filter that cuts the light produced by the laser, so we can see the display without bright light. We consider that our laser device is very useful not for general surgery but also for endoscopic surgery. Histologically, the edge of mucosa that was cut by our laser device is sharp. Therefore, the histological sample is not greatly damaged by heat, which is useful for pathological examination.
When treating a lipoma located in the deep part of the neck where muscles, blood vessels, and nerves are complex, we need not only to avoid complications but also skin incisions considering esthetics. We report two cases of deep-seated lipoma in the neck, which were resected by a short skin incision using the syringe aspiration traction （SAT） method. In the SAT method, the thin coating of lipoma is relatively difficult to tear because the pulling force is not concentrated at one point, and even if the coating is broken, it can be pulled while sucking the parenchyma into the syringe. By properly pulling the lipoma and the incision, a good working space can be obtained even with an incision shorter than the tumor diameter. Therefore, we believe that SAT is a safe method to remove lipomas located in the deep neck.