[in Japanese]

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[in Japanese]

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Pharyngocutaneous fistula （PCF） is one of the most common complications in the early postoperative period after total laryngectomy. We investigated the incidence and risk factors of PCF following total laryngectomy. Sixty patients who had received total laryngectomy at Kagoshima University Hospital between January 2007 and December 2021 were enrolled in this study. PCF developed in 7 patients （12％）, including 4 patients （7％） who had undergone radiotherapy followed by salvage laryngectomy. In salvage surgery cases, the onset of PCF was delayed and also required a longer period of time for its closure. The incidence of PCF was significantly increased in cases with a neutrophil-to-lymphocyte ratio （NLR） of 3 or higher. The results suggest that NLR may be a useful predictor for PCF after laryngectomy, especially in laryngeal cancer cases who have previously undergone radiotherapy.

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We reviewed 27 patients who underwent initial surgery for parotid tumors and whose final pathology diagnosis was pT1-2 low-grade parotid carcinoma. Preoperative fine-needle aspiration cytology was malignant in 10 cases, benign in 10 cases, and difficult to distinguish between benign and malignant in 7 cases. Based on the results of intraoperative frozen section diagnosis, the final surgical procedures were total parotidectomy in 15 cases and shallow/deep lobectomy of the parotid gland in 12 cases. Resection margins were negative in all 27 cases, and there were no cases of pathological intra-parotid multiple carcinoma or lymph node metastasis in the 15 cases of total parotidectomy. All patients had no recurrence, and the 10-year overall survival rate was 100％. It is thought that good outcomes can be achieved in patients with low-grade pT1-2 carcinomas without additional resection by lobectomy or two-stage residual total parotidectomy.

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We report an unusual case of Sjögren’s syndrome with multiple and bilateral parotid cysts.
Case: A 72-year-old woman presented to us with the chief complaint of bilateral parotid nodules accompanied with severe pain. CT revealed multiple cysts in the bilateral parotid glands, and an abscess forming in part of the left parotid gland. Surgery was performed for abscess drainage and tissue biopsy, resulting in a pathological diagnosis of lymphoepithelial sialadenitis （LESA）. Subsequently, we examined whether the primary disease of LESA was HIV infection or Sjögren’s syndrome. As a result of blood examination, a diagnosis of Sjögren’s syndrome was established. Glucocorticoid administration was started 16 days after her first visit to our hospital. The volume of lesions decreased immediately after starting glucocorticoid treatment. A CT scan taken after two months of glucocorticoid treatment revealed complete disappearance of the parotid gland lesions. The patient is due to visit the outpatient hospital regularly to check for the occurrence of MALT （mucosa associate lymphoid tissue） lymphoma.
Conclusion: LESA is a specific pathological finding which is often found in cases of HIV infection or Sjögren’s syndrome. LESA is also known as the primary disease of malignant lymphoma, MALT lymphoma in particular.

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Video-assisted neck surgery （VANS） is a surgical technique that offers superior cosmetic outcomes and is gaining popularity. In this study, we retrospectively reviewed 31 cases （1 male, 30 females） who underwent VANS at our department from June 1, 2019 to July 31, 2023. The patients’ ages ranged from 16 to 66 years, with a median age of 38 years. Preoperative diagnoses included 24 cases of benign nodules and 7 cases of malignant tumors. The surgeries were performed via a subclavian approach for partial thyroidectomy. Tumor sizes ranged from 7 to 45mm （median: 35mm）, and operative times ranged from 89 to 250 minutes （median: 139 minutes）. Most cases exhibited minimal blood loss. Two cases experienced transient recurrent laryngeal nerve palsy, and one case required additional cervical incision. However, there were no cases of postoperative infection or reoperation due to postoperative hemorrhage.

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The purpose of this study was to investigate the outcomes and late adverse events of particle beam radiation therapy for head and neck cancer. Nineteen patients treated with particle beam radiation therapy for head and neck cancer between 2001 and 2023 were retrospectively analyzed for local control, overall survival, and late adverse events. The 5-year local control rate and 5-year overall survival rate after treatment were 73.7％ and 73.7％, respectively. Adverse events after particle beam radiation therapy included brain necrosis, osteonecrosis of the jaw, decreased vision, and necrosis of the pharyngeal mucosa; Grade 3 or higher adverse events were observed in 11 patients （58％） and Grade 5 adverse events in 5 patients （26.3％）. Particle beam radiation therapy is superior in local control of advanced non-squamous cell carcinoma. During the long observation period after particle beam radiation therapy, the morbidity period was prolonged in many cases due to late complications.

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Hypercalcemia is a pathological condition that develops various central nervous system symptoms such as disturbance of consciousness and can be fatal when it gets worse and causes a crisis. We experienced two cases of hypercalcemic crises caused by parathyroid tumors. Case 1 was a 67-year-old woman. A parathyroid malignant tumor was suspected on detailed examination, and was surgically excised and diagnosed as parathyroid adenoma. Case 2 was a 61-year-old woman. A parathyroid malignant tumor with metastasis was suspected on detailed examination, and the primary lesion was surgically excised and diagnosed as parathyroid carcinoma. Postoperatively, the condition of the crisis improved in case 1 but not in case 2, which was thought to be caused by metastatic lesions. For parathyroid tumors with hypercalcemia, surgical excision should be considered first, and if there is no improvement after surgery, it is important to continue to investigate the cause.

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Piriform sinus fistula is a congenital internal fistula observed in the hypopharynx. During fistula removal, which is a radical treatment, identification of the fistula is often challenging because of scarring after infection or because of the incision for draining the abscess. Herein, we report a case wherein intraoperative indocyanine green （ICG） fluorescence visualization was useful for the identification of a piriform sinus fistula. A 39-year-old man was diagnosed with piriform sinus fistula because of a neck abscess at the referring hospital. The fistula persisted despite transoral fistula cauterization; therefore, transcervical removal of the fistula was performed. Identification of the fistula tract was predicted to be challenging because of scarring resulting from abscess drainage; however, ICG injection into the fistula tract under a laryngoscope along with near-infrared fluorescence imaging during surgery facilitated identification and complete removal of the fistula tract.

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Thyroglossal duct cysts develop from the persistence of the thyroglossal duct and are rarely accompanied by malignant tumors. We present two cases of thyroglossal duct carcinoma with cervical lymph node metastasis. In case 1, enlarged lymph nodes with cyst formation were found in the left Level Ⅳ lymph node. In case 2, metastatic lesions were found in the right Level Ⅳ lymph node and the superficial neck near the sternal notch. The frequency of lymph node metastasis from thyroglossal duct cancer is relatively high, but the prone site of metastasis is unknown. In past reports, lateral neck metastasis was the most common at 75％. In case 2, lymph node metastasis beyond the range of standard neck dissection was revealed by PET-CT. It is important to comprehensively evaluate metastasis using various imaging inspections.

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Spinal muscular atrophy is a neuromuscular disorder caused by progressive degeneration of lower motor neurons, resulting in dysphagia. Herein, we report a case of adult-onset spinal muscular atrophy in which staged aspiration prevention surgery was effective in meeting the patient’s desire for oral intake and voice preservation. A man in his 60s, diagnosed with spinal muscular atrophy, had been unable to ingest food orally for one year. Because he desired to regain oral intake ability and speech function, a modified Biller epiglottoplasty with laryngeal suspension and cricopharyngeal myotomy were performed. Although he could take oral enteral nutrition after the initial surgery, aspiration gradually increased again at around nine months. Subglottic laryngeal closure was performed as a staged surgery as the patient wished to prevent aspiration, even at the expense of his voice. The patient had slowly progressive dysphagia, rendering the choice of surgical technique problematic. The staged treatment, performed according to the patient’s desire after careful explanation, managed to preserve his voice function for a certain period.

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The transmanubrial osteomuscular sparing approach （TMA） for apical chest tumors reported by Grunenwald et al. preserves shoulder articulation and provides excellent access to the subclavicular region. We performed modified TMA with resection of sternocleidomastoid muscle （SCM） and major pectoralis muscle in five patients in order to remove head and neck tumor extending to the upper lateral mediastinum. In all cases, exposure of the subclavian vessels was excellent. In four cases, the brachiocephalic vein or subclavian vein was resected. Complete resection of the tumor was performed in four cases. In all cases, favorable shoulder articulation was obtained and the postoperative course was uneventful. We conclude that modified TMA for head and neck tumor extending to the upper mediastinum provides a good surgical view and excellent cosmetic and functional results.

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Tumors arising in the lacrimal drainage system, including the lacrimal sac, are rare, and more than half of epithelial tumors in the lacrimal sac are malignant. Lacrimal sac carcinoma can extend into the orbit, and balancing curative intent with functional preservation is crucial in treatment. Recently, reports of HPV-associated squamous cell carcinoma in the lacrimal ducts have been published. Based on previous reports, HPV-associated squamous cell carcinoma of the lacrimal sac is presumed to show a favorable response to treatment.
The present case was a man in his 60s who developed HPV-associated squamous cell carcinoma in the right lacrimal sac and underwent eye-sparing partial maxillectomy followed by postoperative radiation therapy. The postoperative course was favorable, and the patient was satisfied with the preservation of his eye. This case demonstrates a favorable treatment outcome for HPV-associated squamous cell carcinoma.

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IgG4-related disease is a systemic disease that presents with nodules and thickened lesions in various organs, however, there are few reports of laryngeal lesions of IgG4-related disease. In this report, we describe a case of IgG4-related disease that was suspected to be laryngeal cancer, and was difficult to diagnose. The patient was a 48-year-old man with the chief complaint of sore throat and hoarseness. The patient presented with mass lesions in the left arytenoid, left vocal fold paralysis, and left cervical lymphadenopathy. Biopsy of the left arytenoid revealed no malignant findings. Pathological findings suggested IgG4-related disease, however, a definitive diagnosis was not reached. During follow-up, lung lesions appeared and partial pulmonary resection was performed, which met the diagnostic criteria for IgG4-related disease on pathological examination. We also diagnosed laryngeal lesions as IgG4-related disease. We treated the patient with steroid, however, the vocal fold paralysis remained. Early diagnosis and treatment may improve vocal fold paralysis, so it is important to consider IgG4-related disease when identifying laryngeal tumors.

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Dysphagia occurs in approximately 40％ of cases of deep neck abscess and is a serious complication after treatment. We report a case of severe dysphagia accompanied with a deep neck abscess and mediastinitis who did not improve after long-term rehabilitation, requiring surgery for improving swallowing function which resulted in remarkable success. The case was a 76-year-old man, who underwent an incision drainage operation: tracheotomy for a deep neck abscess. Deglutition rehabilitation was started on the 8th day and he could eat several shares of jelly at best, but he developed aspiration pneumonia on the 161st day, and the ingestion was stopped. He underwent bilateral cricopharyngeal myotomy and laryngeal elevation surgery on the 237th day and received rehabilitation for one month, becoming able to ingest three meals of staple food. Even though progress after treatment for deep neck abscess requires a long time, surgery for improving swallowing function is effective.

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The submental island flap （SIF） is a cervical pedicle flap vascularized by the submental artery, a branch of the facial artery. Although there are numerous reports on the reconstruction of small defects using SIF after oral cancer resection, reports on its use in reconstruction after oropharyngeal cancer resection are currently limited. This report describes two cases wherein SIF was used to reconstruct pharyngeal defects after oropharyngeal cancer resection.
Case 1: A 74-year-old woman with p16-positive anterior wall cancer （cT2N1M0） underwent reconstruction with a 5×2.5cm SIF. The operative time and blood loss volume were 346 min and 280mL, respectively. Oral intake commenced 8 days postoperatively; the patient was discharged 18 days postoperatively, with advice for regular food intake.
Case 2: An 80-year-old man with p16-positive lateral wall cancer （cT2N0M0） underwent reconstruction using a 5×3cm SIF. The operative time and blood loss volume were 374 min and 260mL, respectively. Oral intake began 11 days postoperatively; the patient was discharged 81 days postoperatively, with advice for regular food intake, despite him experiencing two episodes of aspiration pneumonia.
The oncologic safety of SIF reconstruction has been established in oral cancer but remains understudied in oropharyngeal cancer. However, in these two cases, SIF was considered oncologically safe for oropharyngeal cancer reconstruction as the rate of metastasis to level I in oropharyngeal cancer is substantially lower than that in oral cancer.

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Undifferentiated pleomorphic sarcoma is one of the most common malignant soft tissue tumors of the limbs and trunk. In this report, we describe a very rare case of undifferentiated pleomorphic sarcoma in the neck. The patient was an 80-year-old man. A mass was found in his left neck and he was referred to our department. Histological analysis from biopsy tissue revealed a mass that was most likely to be sarcoma. Under general anesthesia in collaboration with the Department of Plastic and Reconstructive Surgery, the patient underwent excision of a malignant tumor from the left neck region, left neck dissection, and a reconstructive surgery using a skin flap. The final histopathological diagnosis was undifferentiated pleomorphic sarcoma. Since then, there has been no residual tumor or recurrence. Undifferentiated pleomorphic sarcoma is a highly malignant tumor and is prone to recurrence and metastasis, so caution is required in its diagnosis and treatment. Although the incidence is not high, malignant soft tissue tumors such as undifferentiated pleomorphic sarcoma are considered to be an important differential diagnosis for neck masses, and preoperative biopsy should be considered prior to treatment planning when necessary.

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