We conducted a retrospective analysis of the oral feeding conditions before and after surgery for 30 amyotrophic lateral sclerosis （ALS） patients who had undergone aspiration prevention surgery in Kamagaya General Hospital for the 6 years from June 2013 to June 2019 and for whom more than 6 months had passed. Surgery for aspiration prevention was performed by total laryngectomy, tracheoesophageal anastomosis and glottic closure with cricopharyngeal myotomy. In patients who underwent total laryngectomy, oral intake was significantly improved immediately after surgery and at 6 months after surgery, and the presence or absence of preoperative aspiration pneumonia did not affect postoperative oral intake. Total laryngectomy is considered to be the best treatment for patients who strongly desire oral intake regardless of preoperative swallowing function.
In the WHO classification, 4th edition revised in 2017, regarding the pathological findings of conventional follicular variant of papillary thyroid carcinoma, non-invasive follicular thyroid neoplasm with papillary-like unclear features （NIFTP） and well-differentiated tumor of uncertain malignant potential （WDT-UMP） have been newly defined as tumors in the boundary region between benign and malignant tumors. We re-examined the pathological findings of thyroid cancer in 11 cases diagnosed as follicular variant of papillary thyroid carcinoma in our department. Of these, 4 cases were follicular variant of papillary thyroid carcinoma, 5 were NIFTP, and 2 were WDT-UMP according to the WHO classification, 4th edition. It was difficult to predict these pathological findings by preoperative ultrasonography, CT, and fine-needle aspiration cytology. In the future, genetic testing by fine-needle aspiration cytology may be used to predict pathological findings before surgery, and individualized treatment may be possible.
We report a retrospective study of 8 oral tongue cancer patients treated in Kyoto Prefectural University of Medicine from April 2017 to November 2019. Inclusion criteria were as follows: primary tumor, more than 2cm in greatest dimension, deeper than 10mm, resected after neo-adjuvant chemotherapy （NAC）, PCE therapy. We evaluated the efficacy and adverse events for NAC and observed the extent of the residual tumor in the permanent section and analyzed the resection line. The completion rate of treatment was 87.5% and 7 cases avoided reconstruction with myocutaneous flap; all the cases underwent the resection with negative margins. From the comparison between the diameter on MRI and in the specimen, the true diameter could be the extent of the tumor on MRI after NAC. When the tumors became fragmented, characteristically they showed a faint contrast, but could not be identified on ADC-map. As a result, it was shown that in limited surgery after NAC, the true range of the tumor could be that on the MRI image after NAC.
Video-assisted neck surgery （VANS） has a cosmetic advantage because of an extracervical approach avoiding a cervical incision. We have been performing VANS with a gasless anterior neck skin-lifting method using an approach from the chest wall since 2016. As for hemithyroidectomy, we compared the outcomes of these patients （VANS group：35 cases） with those of patients treated by conventional open surgery （conventional surgery group：35 cases） from November 2016 to November 2018. The VANS group had 33 women （94.3％）, and the mean patient age was 47.3 years. The VANS method tended to be chosen by younger women and those with a small tumor size. VANS has less bleeding, a longer operation time, and more postoperative drainage compared with conventional surgery. However, the complications associated with surgery were postoperative bleeding in one case, wound infection in one case, and transient paralysis of the recurrent laryngeal nerve in five cases.
We retrospectively analyzed 27 patients suspected of cervical lymph node metastases from an unknown primary site between 2007 and 2017. We classified the patients into three groups. In group A （five cases）, the primary site was found before initial treatment; in group B （eight cases）, the primary site was found after initial treatment; and in group C （14 cases）, the primary site was unknown. The three- and five-year overall survival rates in all cases were 81.8％ and 71.4％ in the group with unknown primary site （C）. There were no deaths in the group with known primary site （B）. The three-year overall survival rate by N classification was 100％ in N1 cases, 84.6％ in N2 cases and no survival in N3 cases. Careful physical examination and laryngoscopy were important for finding the primary site, and PET-CT and tonsillectomy helped make the diagnosis. In addition, our study suggests that whether the primary site is known, whether the case is resectable, and whether the case is N3 are prognostic factors.
In recent years, because of the development of diagnostic equipment, superficial and early-stage cancers have been detected in the hypopharynx or larynx, and surgical techniques have made it possible to remove them from the mouth. Our department also actively performs transoral surgery （TOS）. In the present study, we focused on magnified endoscopic diagnosis used for superficial cancers of the esophagus and retrospectively examined TOS cases, including patients with positive surgical margin or postoperative complications. In the 3 years beginning January 2016, 40 cases and 45 lesions with a diagnosis confirmed through magnified endoscopy were examined. As a result, B2 and B3 lesions were strongly associated with subepithelial infiltration similar to esophageal cancer. The results of the present study pave the way for a proper response to confirmed magnified endoscopic diagnoses before surgery, leading to safe and effective TOS.
A retrospective study was conducted to evaluate the clinical outcomes of 25 patients with mandibular gingival squamous cell carcinoma in our hospital between April 2012 and January 2018. All patients underwent surgical resection. Twenty-one patients had microscopically involved resection margins, extranodal extension, pT4 primary, pN2 or pN3 nodal disease. Ten patients underwent adjuvant postoperative therapy, but 11 patients did not. The 5-year overall survival rates were 63％ in all patients, 100％ in pN0 and 27％ in pN＋. Pathological node metastasis was the most significant predictive factor for 5-year overall survival （p＝0.0003）.
The Japan Society for Head and Neck Surgery established a board certification system for head and neck surgeons. However, the actual situation of board-certified facilities for head and neck cancer （HNC） has never been reported. We investigated the current status of treatment for HNC patients at certified facilities and compared it with that at non-certified facilities by using data from a nationwide cancer registry in Japan. We analyzed the data of 94,006 patients with HNC who were diagnosed between 2012 and 2015 at 705 facilities in Japan, and the prognostic data of HNC patients who were diagnosed between 2009 and 2013 as recorded in the hospital-based cancer registries. A total of 59,789 patients （63.6％） underwent treatment at the board-certified facilities, where younger or more advanced patients were likely to be treated. The treatment guidelines were followed more strictly there. The survival rate of all HNC patients treated in the board-certified facilities was significantly higher than that in the non-certified facilities. Difficult cases and/or cases with a variety of treatment options tended to choose treatment in certified facilities. This study revealed that the board certification system for HNC gradually accomplished its purpose of boosting the quality of patient care in Japan.
We report a case in which urgent surgery was required due to psychological symptoms of Graves’ disease. The case was a 37-year-old woman. She had been diagnosed with Graves’ disease two years earlier. She was started on oral thiamazole, but self-discontinued due to its side effects. Although she was subsequently diagnosed with depression two months later, she refused to take the medication. Her mental state deteriorated and she could not communicate. She was referred to our hospital for the treatment of Graves’ disease. According to a psychiatrist, her psychiatric symptoms were likely to be Basedow’s psychosis. Her condition was so severe that she required hospitalization for medical care and protection. Early improvement of thyroid function was necessary, but drug therapy was difficult due to side effects. Therefore, she was treated with inorganic iodine to normalize her thyroid function. We then promptly performed total thyroidectomy and her mental status stabilized. Basedow’s psychosis may require early surgical intervention. It is necessary for head and neck surgeons to understand and deal with the condition.
We report a rare case of tracheoesophageal fistula which developed 6 years after curative treatment for hypopharyngeal carcinoma and which was successfully repaired by using a pectoralis major myocutaneous flap. A 59-year-old man underwent chemoradiotherapy followed by pharyngolaryngectomy with bilateral neck dissection and free jejunum flap reconstruction. No recurrence was observed after the curative treatment, however, a tracheoesophageal fistula with a diameter of 5mm was detected in the posterior tracheal wall 6 years after the treatment. Surgical repair of the tracheoesophageal fistula was performed, consisting of division of the fistula, transverse suture of the esophagus, covering the esophageal suture by a pectoralis major myocutaneous flap, and reconstruction of the tracheal defect with the skin of the flap. The postoperative course was favorable. It was considered that the tracheoesophageal fistula of this patient was caused by poor blood circulation after the chemoradiotherapy and surgery. Pectoralis major myocutaneous flap with abundant blood circulation was useful as an interposed flap for reliable repair of the tracheoesophageal fistula.
Streptococcal toxic shock syndrome （STSS） is a serious and highly fatal infection. Patients without underlying disorders such as immunodeficiency can rapidly develop soft-tissue necrosis, acute renal failure, adult-type acute respiratory distress syndrome （ARDS）, disseminated intravascular coagulation （DIC）, and multiple organ failure （MOF）. It occurs mostly in the limbs and is rare in the head and neck region. We report a case of STSS originating from the right neck. A 65-year-old man underwent partial resection of the tongue and right neck dissection （1-Ⅳ） for tongue cancer （T3N0M0）. With a 3-day history of exudate from the wound and 1-day history of sore throat and fever, he was diagnosed with septic shock. Meropenem, Linezolid, large amounts of fluids, and noradrenaline were administered. The gross appearance of the exudate from the wound was ginger-like, and the gram-positive cocci in chains were identified as group A beta-hemolytic streptococci （GAS）, Streptococcus pyogenes. The patient was finally diagnosed as having streptococcal toxic shock syndrome （STSS）. Although the antibiotics were switched to Meropenem/Clindamycin, his condition rapidly deteriorated. Serotypes of GAS were T12, M12, and emm12. Superantigens speB and speF were present. GAS is a common cause of sore throat and sometimes can cause STSS. Although it is a rare disease in the head and neck region, it must be taken into consideration as one of the differentiating treatments.
Odontogenic myxoma is a relatively rare benign tumor of the maxillary or mandibular bone. Surgery is the first-choice elective treatment because odontogenic myxoma causes facial deformity or diplopia. The surgical procedure remains controversial. Some surgeons perform disfiguring radical surgery and others favor simple enucleation with curettage. A 40-year-old woman visited our hospital with complaints of right cheek discomfort and nasal congestion. A CT and MRI scan showed a 44 mm-sized tumor in the right maxillary sinus. Under local anesthesia, a biopsy of the maxillary sinus was performed via the transnasal passage, and the tumor was diagnosed with odontogenic myxoma. Under general anesthesia, the procedure of endoscopic modified medial maxillectomy （EMMM） and curettage after tooth extraction was performed. By performing EMMM and tooth extraction concurrently, the tumor could be approached from both the extraction socket and the nasal cavity, and it was possible to perform curettage reliably with a good field of vision.
There is a wide variety of histological types of middle ear tumors, including glomus tumors, schwannomas, adenomas and hemangiomas. Among them, middle ear adenoma is an extremely rare disease that can arise anywhere in the middle ear cavity. It is often difficult to differentiate preoperatively because of its nonspecific clinical findings. The diagnosis of middle ear adenoma can be confirmed by histopathological examination. However, it is difficult to distinguish it histopathologically from carcinoid tumor of the middle ear, and they are considered synonymous with the disease. We herein report a rare case of middle ear adenoma suspected as glomus tumor preoperatively. The patient was a 67-year-old female who presented with right pulsatile tinnitus and hearing loss. Otoscopic examination revealed a reddish and pulsatile mass in the tympanum through the tympanic membrane. CT demonstrated a mass localized in the meso- and hypotympanum without bone destruction. MR images revealed a tumor that was strongly enhanced by gadolinium. These findings led us to a diagnosis of glomus tympanicum tumor. Preoperative angiography findings revealed that the tumor was fed by the branch of the middle meningeal artery. The tumor was resected en bloc after embolization of the feeder vessel. The pathological diagnosis of the excised specimen was middle ear adenoma. No recurrence has been noted to date, 11 months after surgery. The findings of this case suggest the necessity of including middle ear adenoma in the differential diagnosis, even if a tumor strongly suspected as glomus tumor is observed in the middle ear.
The patient was a 58-year-old man who had complained of a right neck mass. During maintenance dialysis, a biopsy was scheduled for right-neck lymphadenopathy in our hospital, but tumorous lesions were observed in the right palate tonsil. DWIBS was performed, and the imaging suggested cervical lymph node metastasis of oropharyngeal carcinoma. The results of the palate tonsil biopsy were p16 positive squamous cell carcinoma. Oropharyngeal carcinoma （T2N1M0） was cured by radical radiotherapy. One year after treatment, there has been no recurrence. DWIBS was an excellent medical and economical hospitalization modality compared to PET-CT. In addition, there is no contrast agent or radiation exposure, it is not affected by diabetes, and it imposes little burden on patients.
Malignant tumors in the lacrimal sac are relatively rare. The symptoms are similar to chronic dacryocystitis, and so treatment is often delayed. We encountered two patients, an adenocarcinoma case and a squamous cell carcinoma case, who received treatment for chronic dacryocystitis. Both cases underwent partial maxillectomy with orbital clearance. The adenocarcinoma case had local recurrence, underwent chemoradiotherapy, and survived with no evidence of disease. The SCC case underwent adjuvant chemoradiotherapy and survived with no evidence of disease. The principal treatment for lacrimal sac cancer is surgical removal. A multidisciplinary approach should be considered according to the histological types and extent of disease.
Angiosarcoma is a rare soft tissue malignancy that accounts for 2％ of soft tissue sarcomas. Most cases of angiosarcoma in the head and neck originate in the skin of the head; those originating in the oropharynx are extremely rare. We experienced a case of oropharyngeal angiosarcoma with multiple distant metastases from the first visit. The prognosis for angiosarcoma is very poor. Especially for those with distant metastases, the median survival time was reported to be about 3 months, and there is no clear treatment policy with evidence. In the present case, chemotherapy with paclitaxel resolved the oropharyngeal lesion. Although the distant lesion had also shrunk, a new distant lesion appeared and increased, so we changed the chemotherapy to pazopanib. Paclitaxel had a progression-free survival （PFS） of 6 months and an overall survival （OS） of 17 months. A case report is made, with a review of the literature.
A 27-year-old woman suffered from dyspnea, caused by an accident. She underwent tracheostomy after prolonged endotracheal intubation. She had severe laryngeal stenosis, but desired to close the tracheostoma. In this case, we had to evaluate the stenosis and consider how to treat it. We performed microlaryngeal surgery under general anesthesia. The anterior part of the glottis was adhesive and the subglottis was filled with scar tissue. The posterior part was intact and the cricoarytenoid joints were not fixed. These results showed that the glottis could be enlarged by the laryngofissure technique, removing the scar. The operation was performed under general anesthesia and the scar was removed. We succeeded in establishing a sufficient airway, and the laryngeal cutaneous fistula was closed six months later. We are now planning to close the tracheostoma.
Congenital cholesteatoma of the tympanic membrane is an extremely rare pathological condition, and very few cases have been reported. We report the case of an 11-year-old boy with cholesteatoma of the left tympanic membrane who underwent endoscopic tumor resection with an uneventful postoperative course. It is generally understood that inflammation-induced basal cell proliferation of the cutaneous layer of the tympanic membrane causes cholesteatoma in patients with a history of otitis media. On the other hand, aberrant squamous cells during the embryonic period are considered to result in the disease in patients without a history of otitis media. Cholesteatoma has been reported to invade the tympanic cavity and destroy the auditory ossicles; thus, in principle, surgical treatment is preferable. Resection of the cholesteatoma was performed using an endoscope, which provided us with a clear view of the layers to be dissected, enabling us to spare the middle layer of the tympanic membrane. Therefore, this method was found to be effective.