Unilateral vocal cord paralysis causes hoarseness and aspiration, and reduces the quality of life of the paralyzed patient. For these patients who cannot spontaneously recover, atrophy can be improved through medialization of the paralyzed vocal cord by reinnervation of the recurrent laryngeal nerve. Though this technique is widely recognized, improvement of symptoms cannot be observed until several months after the reinnervation. Rapid reduction of symptoms with additional improvement of voice quality can be acquired by arytenoid adduction combined with reinnervation of the recurrent laryngeal nerve within the same operative field. Ten patients with unilateral vocal cord paralysis underwent this procedure. Rapid improvement of maximum phonation time （MPT） was observed postoperatively, and additional prolongation of MPT was recognized more than 7 months later. A statistical difference was observed between preoperative MPT and postoperative MPT. Subjective voice assessment employing the GRBAS scale identified improvement of overall grade （G） from the preoperative to postoperative period and more than 7 months later. Improvement was identified in vocal quality of breathiness from the preoperative period to the same periods. This technique is more favorable than reinnervation alone, because rapid reduction of symptoms can be acquired postoperatively.

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Transoral resection for pharyngeal carcinoma is less invasive than external incision and superior in terms of function preservation, complications and duration of treatment. However, from the point of view of tumor control, it is important to control not only the primary tumor but also recurrence in cervical lymph nodes. Cases were selected in consideration of the effects of double cancer, and pathological factors associated with cervical lymph node recurrence were examined. No pathological factors were found to be significantly associated with postoperative cervical lymph node recurrence in patients with oropharyngeal carcinoma. However, in patients with hypopharyngeal carcinoma, tumor thickness of 1.8mm or more was significantly associated with cervical lymph node recurrence. Lymph node recurrence is controlled by additional treatment in all cases, suggesting that prophylactic neck dissection could be avoidable.

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We retrospectively reviewed 136 patients （111 women and 25 men） who underwent operations for primary hyperparathyroidism （PHPT） between April 2008 and September 2018 at Sapporo City General Hospital. We have been conducting intraoperative parathyroid hormone monitoring since 2014, so we divided the patients into two groups: intraoperative parathyroid hormone monitoring （67 patients, 11 men and 56 women） or no monitoring （69 patients, 14 men and 55 women）. In the non-monitoring group were 4 patients with recurrent PHPT, whereas the monitoring group had no patients with recurrence. Thus, recurrence in the monitoring group was lower than that in the non-monitoring group. In a previous report, intraoperative parathyroid hormone monitoring was found to be more effective that judging the excised tumor of the parathyroid gland such as adenomas than non-monitoring. Our review found the same result.

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Background. Head and neck cancers account for a relatively large number of second primary malignancies （SPM）. It is important to search for SPM in the head and neck area and the upper gastrointestinal tract. In addition, there are few reports in Japan on the risk of SPM of oral cancer.
Methods. A retrospective study was conducted on 155 oral cancer patients treated at our hospital.
Results. There were 47 cases that developed SPM, in which 11 developed synchronously and 39 developed metachronously: three cases developed SPM both synchronously and metachronously. The risk factors for SPM were smoking history of 25 packs/year or more for synchronous SPM and 37 packs/year or more and age （67 years or older） for metachronous SPM, and fewer than three cases of young or non-smoking metachronous SPM of the upper gastrointestinal tract.
Conclusion. Duplicate cancer search is less likely to focus on the upper gastrointestinal tract in younger or non-smoking patients.

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Objective: The purpose of this study was to propose a V-shaped incision （VSI） and to compare cosmetic incisions, including modified facelift incision （mFLI）, retroauricular hairline incision （RAHI）, and VSI, with the conventional modified Blair incision （MBI） in terms of complications and esthetic outcomes for the treatment of benign parotid gland tumors.
Methods: We reviewed the clinical data of 37 patients who underwent partial parotidectomy as the primary treatment for benign parotid tumors between January 2017 and September 2019. The patients were divided into the MBI and mFLI/RAHI/VSI groups. Operation variables and cosmetic satisfaction of matched pairs were compared between the two groups.
Results: Twenty patients underwent conventional MBI, five patients mFLI, seven patients RAHI, and five patients VSI. The external ear canal cartilage, mastoids, the anterior edge of the sternocleidomastoid muscle, and the posterior belly of the digastric muscle could be visualized using VSI and therefore the tumor could be resected while identifying the main facial nerve trunk. The postoperative wound was localized around the ear lobe because there was no incision line from the posterior auricle to the mastoid process. We selected mFLI/RAHI/VSI over MBI for tumors that were significantly small and not anterior. The operation time and complications, including facial palsy, Frey’s syndrome, salivary fistulas, and wound problems, did not differ between the two groups. Reponses to the questions “Is the scar visible?” and “Do you want more esthetic surgery?” did not significantly differ between the two groups.
Conclusion: mFLI, RAHI, and VSI are safe and preferable approaches for parotidectomy, especially for tumors that are small and not anterior.

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We examined 224 patients who underwent surgery for parotid lesions during the 8 years from January 2012 to December 2019. There were 192 benign lesions, with pleomorphic adenoma and Warthin’s tumor in 92 （47.9％） and 59 cases （30.7％）, respectively. Furthermore, 32 patients had malignant tumors. The accuracy of fine-needle aspiration cytology was 80.4％ and 62.7％ for pleomorphic adenoma and Warthin’s tumor, respectively. The positive diagnosis rate of malignant tumors was 75.0％ for highly malignant tumors and 27.3％ for low- and middle-grade malignant tumors. Among the benign cases, the anterograde and retrograde approaches were used in 130 and 56 cases, respectively. Postoperative facial nerve palsy was observed in 25.0％ of the benign cases, with complete recovery observed in all but four cases. Of the four patients with residual facial palsy, three had paresis, while the remaining patient had a facial schwannoma for which intercapsular resection was performed, although complete paralysis persisted. The incidence of postoperative facial nerve palsy according to location was 21.1％, 27.8％, and 28.9％ for superficial lobe tumors, deep lobe tumors, and tumors in the lower pole, respectively. The incidence of postoperative facial paralysis based on the approach was 23.7％ and 33.9％ for the anterograde and retrograde approaches, respectively, with no significant difference between them. The average surgery time was 139.7min for benign cases and 180.0min for superficial and deep lobe tumors. In terms of the approach to the facial nerve, the anterograde and retrograde approaches averaged 156.6min and 120.6min, respectively, the difference being significant. The operation time and postoperative hospital stay were significantly shorter for the retrograde than for the anterograde approach. It may be useful to select the surgical approach based on the localization of the lesion.

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A total of 49 patients with head and neck cancer treated with concurrent chemoradiation with cisplatin （CDDP） in our department between April 2013 and December 2017 were studied retrospectively to determine the necessity and therapeutic effect of gastrostomy nutrition. Gastrostomy nutrition was used in a total of 30 patients; usage was lower in patients with laryngeal cancer than in those with pharyngeal cancer. Gastrostomy nutrition did not correlate significantly with the disease-free survival, overall survival, or cumulative cisplatin dose. Patients who received prophylactic irradiation to the entire neck were less likely to use gastrostomy nutrition than those who received definitive irradiation to neck lymph node metastasis. The use of gastrostomy nutrition was more common in patients with a pre-treatment weight of less than 64kg, in whom gastrostomy nutrition tended to prevent weight loss during treatment.

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Skull base osteomyelitis （SBO） usually occurs in the temporal bone secondary to otitis externa. An atypical form, now termed central skull base osteomyelitis （CSBO）, is centered on the sphenoid and occipital bones rather than the temporal bone. It is caused by the spread of infection from the middle ear, sinuses, etc. in addition to the external auditory meatus, and is difficult to differentiate from malignant tumor. A 74-year-old woman with diabetes had been treated with Pseudomonas aeruginosa for acute otitis media six months ago, and then had an eardrum tube inserted due to exudative otitis media. She had a headache and went to the referral hospital. At the time of visit to our hospital, no evidence of infection was found and a malignant tumor was suspected. However, nasal endoscopic nasopharyngectomy revealed an abscess in the deep nasopharynx. Pseudomonas aeruginosa that was consistent with the causative agent of otitis media half a year ago was detected. If subtle clival erosion is observed, it is necessary to pay attention to the past infection history and slight inflammatory reaction with skull base osteomyelitis. Nasal endoscopic nasopharyngectomy enables the exclusion of malignant tumors, extensive excision of lesions, culture from deep lesions, and identification of postoperative cultures.

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Patients presenting with a suspected medullary thyroid carcinoma （MTC） undergo preoperative testing which can include fine needle aspiration cytology （FNAC） together with calcitonin and carcinoembryonic antigen （CEA） testing. In addition, both the US and Japanese Guidelines for MTCs currently recommend preoperative genetic testing to determine whether the carcinoma is sporadic or hereditary because one-third of MTCs are hereditary and are linked to RET gene mutations. Sporadic MTCs can be treated by a hemithyroidectomy while hereditary MTCs should be removed by a total thyroidectomy including removal of associated lymph nodes. We describe herein four such patients who were ultimately confirmed to have an MTC, and the course of their treatment including those who underwent RET genetic testing. While not all of our patients underwent RET genetic testing, our experience demonstrates that RET genetic testing is an essential tool which should be included in the preoperative diagnostic surgical planning of patients presenting with MTCs.

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The case of a 73-year-old man with acute invasive fungal sinusitis involving the left orbital apex is described. The diagnosis of fungal disease was based on clinical presentation including severe visual loss, computed tomography and magnetic resonance imaging of the paranasal sinuses and histopathological findings. Intravenous anti-fungal therapy （Voriconazole） and extended resection surgery including orbital exenteration were implemented. During 2 years and 5 months follow-up, the patient did not show recurrence of sinusitis. Invasive fungal sinusitis can rapidly spread beyond the sinus cavity into the intracranial space and orbit causing a life-threatening condition. Recently, more cases treated without orbital exenteration have been reported owing to the recent progress in endoscopic sinus surgeries （ESS）, in addition to the development of antifungal drugs with fewer side effects, which made the long-term use of antifungal drugs possible. However, there are cases where systemic administration of antifungal drugs and ESS alone cannot control the progression of the disease. We report our experience of this case of invasive fungal sinusitis treated with orbital exenteration and discuss the indications for extended resection surgery.

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We report a case of a giant functional parathyroid cyst without uptake identified by Tc-99m-methoxy-isobutyl-isonitrile （MIBI） scintigraphy. The case was a 74-year-old woman. The patient was admitted to our hospital because of hypercalcemia and high int-PTH. She was aware of dry mouth and general malaise. High caemia and high int-PTH were noted. CT scan and ultrasound found a cystic mass in the right neck and a solid mass in the left cervical thyroid gland and on the dorsal side. The results of cytology int-PTH showed a high value in the right cervical cyst, but MIBI scintigraphy showed abnormal accumulation in the left cervix. Pathological examination led to a diagnosis of right functional parathyroid cyst, left adenomatous goiter, and left parathyroid hyperplasia. One year has passed since the operation, and the course of recovery is good.

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Surgery for hemophiliacs needs to be supplemented with coagulation factors perioperatively. We report bilateral tonsillectomy and lingual tonsillectomy in a patient with sleep apnea syndrome who had been diagnosed with hemophilia. The case was a 52-year-old man. He had apnea for 20 years and was diagnosed with severe sleep apnea syndrome by a previous doctor. Swelling of the palatine tonsils and lingual tonsils was noted. He strongly requested surgical treatment and was referred to our department. In addition to hemophilia B, he was given an antiplatelet drug, so we repeatedly recommended conservative therapy. However, surgery was performed based on his strong hope. During the perioperative period, a factor Ⅸ preparation was administered. Tracheotomy was also performed in preparation for airway problems. Bleeding was observed temporarily after the operation, but hemostasis was obtained by increasing the dose of Factor Ⅸ preparation. Postoperative subjective symptoms disappeared and PSG also improved.

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Actinomycosis is a chronic infection caused by Actinomyces, gram-positive, anaerobic bacteria, which are normal constituents of the human oral flora, and frequently affects the cervicofacial region. However, sinonasal actinomycosis has rarely been reported. Actinomycosis of the paranasal sinus mostly occurs in the maxillary sinus; ethmoid sinus actinomycosis is extremely rare. Herein, we report a case of actinomycosis of the ethmoid sinus.
An 81-year-old woman was referred to our department for right nasal obstruction and rhinorrhea. She had previously received antibiotic therapy; however, the symptoms persisted. Nasal endoscopy showed a right nasal polyp, purulent discharge and septum deviation to the left. CT showed an expansive mass in the right ethmoid sinus, deviating the nasal septum. We performed endoscopic sinus surgery, and found sulfur granules in the expanded right ethmoid sinus. Bone destruction was not apparent around the sinus. The histopathological examination revealed actinomycosis. We administered oral amoxicillin for 2 months after the operation. The patient had no recurrence during 13 months of follow-up.
The standard treatment for actinomycosis is long-term antibiotic therapy. On the other hand, in recent reports, cervicofacial actinomycosis without bone involvement has shown a good response to treatment with surgical debridement and short-term antibiotic therapy （2-6 weeks）. In actinomycosis of the paranasal sinus, short-term oral antibiotic therapy with surgical debridement has also been reported to be successful in several papers. For actinomycosis in the paranasal sinus, antimicrobial treatment can be shortened if surgical excision has been performed properly.

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A 46-year-old female with metastatic follicular thyroid carcinoma underwent treatment by radio-iodine therapy. Though this has the possibility of exacerbating carcinoma, she hoped to become pregnant after infertility treatment and succeeded, and delivered a healthy female child safely. However, she suffered rapid growth of the carcinoma and a newly metastatic region. Her Activities of Daily Living declined because of metastatic bone regions. A thyroid tumor may progress during pregnancy due to hormonal changes. Although pregnancy is not contraindicated in cases with metastatic thyroid cancer, it is important to recognize that the cancer can progress rapidly.

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Neuroendocrine tumors of the head and neck are rare. The malignant potential of neuroendocrine tumors tends to be higher than that of squamous cell carcinoma. Moreover, the pathologic classification has been the subject of great debate over the years. We report herein two cases of neuroendocrine tumor of the epiglottis.
The first case was a 67-year-old male who had sore throat and hoarseness. An ulcerous legion was observed on the swelling side of the epiglottis, and the result of a biopsy of the lesion suggested poorly-differentiated adenocarcinoma. The findings of imaging studies （CT, MRI and PET） showed no evidence of metastasis, and the stage of the tumor was diagnosed as T1N0M0. Horizontal partial laryngectomy was performed. The pathological diagnosis was a neuroendocrine tumor grade 2 （NET G2）. Although the resection margin was negative, the patient developed postoperative lymph node metastasis to the neck, which was not controlled by subsequent bilateral neck dissection. The patient died 18 months after the first surgery. 　The other case was an 80-year-old male whose epiglottic tumor was discovered by follow-up endoscopic examination after total gastrectomy for stomach cancer. A biopsy of the protruding lesion on the swelling side of the epiglottis suggested neuroendocrine tumor. Based on the findings of imaging studies （CT, MRI and PET）, the stage of the tumor was diagnosed as T2N0M0. Total laryngectomy was performed and the pathological diagnosis was a neuroendocrine carcinoma grade 3 （NEC G3）. Although microscopic infiltration of the tumor cells into veins and lymphatic vessels was found, additional therapy was not performed because of the age of the patient. The patient developed lymph node metastasis on the left posterior region of the neck 28 months after the surgery. Additional therapy is not being performed due to the patient’s age.

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