Objectives : The potential spread of laryngeal cancer was investigated by the analysis of lymphatic vessels' distribution in the normal larynx. The study involved immunostaining for the lymphatic endothelial marker, D2-40, and expression patterns of laminin gamma 2 chain (LN_γ2) in laryngeal cancer.
Results : In the normal larynx we found that many lymphatic vessels existed in the submucosal region except for the vocal cord. In addition, lymphatic vessel density in the pre-epiglottic space and the cricoid area were lower than in the submucosal region, and there were few lymphatic vessels in paraglottic space. In laryngeal cancer specimens, lymphatic vessels existed in 12 out of 23 cancer tissues. Of these twelve patients, five showed cervical lymph node metastases or recurrences. The eleven other patients whose cancer tissues were negative for lymphatic vessels didn't show metastases or recurrences (p< 0.02). We also defined three patterns of LN_γ2 expressions in laryngeal cancer ; peripheral expression, diffuse expression and no expression. The disease's specific cumulative survival rates for patients with diffuse expression and the other expressions were 58% and 100%, respectively (p< 0.05).
Conclusion : The presence of lymphatic vessels and diffuse expressions of LN_γ2 indicate a considerable risk for cancer progression and are closely related to the prognosis. These factors may be prognostic in-dicators for squamous cell carcinomas of the larynx as well.

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An important clinicopathologic focus, with regard to the directional progress of laryngeal cancer, is the anatomical concept called “laryngeal compartment” involving the preepiglottic space (PES) and the paraglottic space (PGS).
In this study, the authors reviewed a primary case of supraglottic cancer for which a supraglottic horizontal partial laryngectomy had been performed in our department. We recognized the new spread into the laryngeal compartment using a large-section preparation of the primary supraglottic cancer for which a total laryngectomy was performed and then conducted a retrospective review for an adaptation of a supraglottic horizontal partial laryngectomy.
Local recurrence in post supraglottic horizontal partial laryngectomy cases was frequently observed, particularly in those involving the laryngeal ventricle, the vocal cord on diseased side, the anterior commissure and PES invasion.
For treatment involving large-section preparation of the larynx and a laryngeal compartment, the authors believe that the supraglottic horizontal partial laryngectomy can be adopted in cases in which the tumor has progressed into the PES and where invasion into the laryngeal ventricle and vocal cord was small.

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喉頭垂直部分切除術 (front-lateral partial laryngectomy) は主に放射線治療後再発声門癌T1および声門下進展の軽度なT2症例を適応として当科では過去7年間に45例に対し施行された.本法の腫瘍摘出までの手順の概要は以下の通りである.甲状軟骨正中を切除・輪状甲状間膜を切除し内腔にアプローチ・健側声帯を切除し喉頭内腔を展開・患側の傍声門間隙を剥離。患側の声帯後方を切除し摘出する.これら切除マージンはいずれも数mm～10mm程度であり, 他の頭頸部癌の切除時に比べ極めて小さい.今回当科において手術 (喉頭全摘術および喉頭垂直部分切除術) を施行した声門癌を対象とし, これらの切除標本を用いて腫瘍の各方向の進展形式を検討した (全摘標本88例, 部切標本45例)
検討項目は,
(1) 下方進展 : 声門下の進展形式
(2) 側方進展 : 傍声門間隙・甲状軟骨近傍の進展形式
(3) 体側進展 : 前連合近傍の進展形式
(4) 後方進展 : 声帯突起近傍の進展形式
の4点である.
これらから声門癌の立体的な進展形式と解剖学的なbarrierを確認し, 喉頭垂直部分切除術が現在の適応症例に対し安全な術式であるのか.また声門下進展例や甲状軟骨浸潤等の進行例が適応となる可能性があるのかを考察する.

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Ten years have elapsed since we employed our first supracricoid laryngectomy with cricohyoidoepiglottopexy (SCL-CHEP) in 1997. We conducted a clinicopathological analysis using 40 surgical specimens obtained between 1997 and 2007. Surgical margins were evaluated at anterior, inferior, superior, and inferior ends and found to be sufficient. Only the inferior ends had minimum margins and the risk for positive margins. Of the 40 patients examined, 4 died of disease, 2 died of other causes, and 34 were alive without disease (average follow-up duration was 36 months). The locoregional recurrence rate was 5%.
We confirmed the stable oncological results based on the current study. In particular SCL-CHEP proved to be capable of sufficiently removing the paraglottic space. For the tumors with profound ulceration in the subglottic region, meticulous effort must be made to properly assess the tumor extention.

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喉頭癌の術式において喉頭部分切除術は有力な選択肢の一つとなっているが, 根治切除のための適切な安全域の設定が重要であることは言うまでもない.切除範囲の決定は内視鏡所見もしくは直接喉頭鏡所見による粘膜病変の広がりとCTやMRIによる深部進展の評価を総合的に判定して行うが, 最終的には術中の病変の広がりを直視下に観察しながら行うことになる.一般に喉頭癌における粘膜下進展は下咽頭癌に比べ限定的で, それ故, 下咽頭癌の切除範囲よりもより安全域を狭く設定できるとされる.本発表の目的は原発巣周囲組織への粘膜下病変の広がりや多発病変の有無の程度を検討すること, および腺系癌について扁平上皮癌との粘膜下進展の違いを検討することである.
喉頭扁平上皮癌における検討対象は喉頭全摘大切片標本による検討が可能であった55例である.年齢は平均68才.男性51例, 女性4例.内訳は声門型が11例, 声門上型が27例, 混合型が14例, 声門下型が1例, 喉頭全体が腫瘍に置換し原発亜部位が分からないものが2例.原発巣周囲組織への平均粘膜下進展距離は声門型で4.3mmであるのに対し, 声門上型で8.2mm, 混合型では10.5mmと大きい傾向が見られた.また, 55例中4例 (7.3%) に多発病変を認めた.
一方, 喉頭に発生する悪性腫瘍の大部分は扁平上皮癌であり, 腺系の癌が発生する.頻度は極めて稀である.当施設での検討では, 喉頭に発生した腺系の癌は過去35年間で10例/643例 (1.5%) であった.組織型の内訳は腺癌2例, 腺扁平上皮癌2例, 腺様嚢胞癌3例, 粘表皮癌3例であった.その内, 病理学的検索が可能であった7例を検討対象とした.腺系の癌は一般に喉頭粘膜下の喉頭腺由来と考えられており, 扁平上皮癌にくらべて粘膜下病変が主体となる症例が多かった.

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咽喉頭逆流症 (以下 : LPRD) に関する最近の報告を総合すると, その病態は単純に胃食道逆流症 (以下 : GERD) の一部あるいは延長線上といえない部分があり, ここではその病態をGERDとの違いに言及しながら解説する.
I.LPRDの病態
1.直接障害説の病態
直接障害では酸が咽喉頭に直接暴露することで, 咽頭通, 嗄声, 肉芽腫などをきたす.GERDと同様pH4未満の酸性の逆流がLPRDの発症に重要と考えられているが, 酸に対する咽喉頭粘膜の脆弱さゆえ一日に数回の胃酸の暴露でも咽喉頭には症状が出るとされている.また同様の理由でpH4以上の弱酸性の逆流でも症状や所見が生じるとする報告がある.このような例では胸やけなどのGERD症状を有さずに咽喉頭症状のみしか有さない例がある.以上より米国の耳鼻咽喉科医の間ではLPRDとGERDは異なった病態であるとする論調が主流であった.しかしながら一方で近年欧米の消化器専門医からは「GERDが重症化するほど咽喉頭症状の有症率が高くなる」など, GERDの延長線上の病態としてLPRDをとらえる報告も出てきている.
2.反射説の病態
下部食道への逆流により迷走神経反射を介して咳などが生じるとするものである.われわれは, 健常成人の食道に胃酸と同濃度のHCLを注入するとUES (UpPer esophageal sphincter) 圧の上昇に伴い咽喉頭圧迫感が生じることを報告した.この際同時にpHモニタリングを施行したところHCLは上部食道・下咽頭には達していないことが分かったため圧迫感が反射により生じることが示唆された.この現象は下部食道への酸逆流を感知した反射的気道防御ととらえることが出来る.米国での研究では, 下部食道への逆流は酸度の上昇と圧上昇の両方により感知されることがわかっている.

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A cough is a common diagnostic and therapeutic problem. The three categories of coughing are acute, lasting less than 3 weeks, prolonged (subacute), lasting 3 to 8 weeks, and chronic, lasting 8 weeks longer. Most cases of prolonged and chronic dry coughing in Japan are due to cough variant asthma, atopic cough, postinfectious cough and gastroesophageal reflux induced cough.
A gastroesophageal reflux associated cough may occur in the absence of gastrointestinal symptoms. Gastroesophageal reflux induced coughing frequently improves with proton pump inhibitors. Intensive acid suppression with proton pump inhibitors should be undertaken for a minimum of 3 months. Coughing can induce gastroesophageal reflux episodes, a cough-gastroesophageal reflux self-perpetuating cycle may be involved in the pathophysiology of a patient's prolonged and chronic cough. Patients with cough variant asthma frequently (approximately 40%) experience complications with gastroesophageal reflux.

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Laryngopharyngeal reflux disease (LPRD) can manifest itself as throat discomfort and chronic cough. This article includes adult cases as well as an infant diagnosed with LPRD. With regard to the adults, the study involved the following two sections. 1) 74 patients (28 male and 46 female) with throat dis-comfort and chronic cough were studied. The influence of LPRD was observed in 68% of these patients. 2) I examined the F-scale, which was a questionnaire regarding gastroesophageal reflux disease (GERD) in 34 patients (11 male and 23 female). 55% were higher than eight points on the F-scale. The F-scale involved a PPI test as well. LPRD was a significant cause of the throat discomfort and the chronic cough patients experienced. As for the infant case, the study involved the following two sections. 1) The symptoms of infant GERD and a summary of the diagnosis and treatment. 2) My comments were noted with respect to laryngomalacia and its relationship to infant GERD. This condition with an infant is rare opportunity for an otolaryngologist to observe, and it proved essential that the observer understand the principle concepts of this disease.

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Objective : To clarify the pathological mechanism of LPRD by studying the histological changes of the pharynxes and the larynxes in rats with chronic acid reflux esophagitis.
Methods : An experimental rat model of chronic acid reflux esophagitis was surgically created. The pharynxes, larynxes, tracheas, lungs and esophagi of these rats were observed histologically every 2 weeks until 20 weeks after their operations.
Results : At 8 weeks after the operation, mucosal thickening and inflammatory cell infiltration was observed in the hypopharynx of the rat model. Moreover, chronic inflammation with proliferation of fibroblasts, deposition of collagen fibers and proliferation and dilatation of the capillaries was found as time progressed. However, little macroscopic change was observed in the hypopharyngeal mucosa. In addition, at 16 weeks post-operation, inflammatory cell infiltration was identified in the nerve cells around the thoracic esophagus, the arytenoid region, and the lungs.
Conclusions : The histological changes of the pharynx and the larynx associated with surgically induced chronic acid reflux esophagitis were observed in rats. Chronic inflammatory change due to gastric acid reflux was found in the pharynx and larynx microscopically. This finding indicated that inflammatory changes due to gastric acid reflux are associated with the pathogenesis of laryngopharyngeal reflux disease (LPRD).

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The term “voice therapy”, which is commonly called “onsei-chiryou” in Japanese, includes vocal rest, vocal hygiene, and vocal modification training. In this paper the focus of the discussion was on vocal modification training, which is called “onsei-kunren” in Japanese. In most cases, speech therapists should be responsible for vocal modification training. The purposes, conditions for application, and 6 categories of the training were proposed. Among the categories, the rationale and training procedures for the modification of loudness, pitch, and voice quality were explained concisely. In order to demonstrate some clinical results of the efficiencies of vocal modification training, previously presented results for cases of functional voice disorders, vocal nodules of children, and spasmodic voice disorders were reported. Finally, 5 essential issues when conducting voice therapy were pointed out. They were ; (1) establishing the criteria for the application of therapy, (2) developing the technical skills with the theoretical bases, (3) the effort to assess therapy outcomes objectively, (4) an efficient team approach with medical doctors and speech therapists, and (5) to provide the patients with warm and helpful advice to reduce their psychological and social problems with voice disorders.

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It has become recently well known that voice therapy is an effective method to treat voice disorders conservatively. We introduced voice therapy for various kinds of voice disorders. 224 cases (73 males and 151 females) with voice disorders were treated at Ehime University Hospital 1998 and 2008. The wide range of maladies consisted of vocal nodules, laryngeal granulomas, sulcus vocalis and atrophies, vocal fold paralyses, and functional voice disorders. Methods of treatment included vocal hygiene education, laryngeal relaxation maneuvering, abdominal breathing, pitch adjustment, resonant voice therapy and the accent method. In performing a structured therapeutic program, the needs of each patient should be considered. Close cooperation between otolaryngologists and speech therapists is mandatory. Surgical management should be considered in cases where insufficient improvement has resulted from voice therapy.

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Dysphonia is one of the symptom of gastroesophageal reflux disease (GERD). We examined the relationship of dysphonia and reflux in sleep disorder patients. A sample population of 208 answered questionnaire about presence of dysphonia during the course of study. Of the 208 responders, FSSG (frequency scale for the symptoms of GERD) questionnaires were further conducted on 170 (81.7%) and 135 (64.9%) had laryngeal fiberscopy exams. 37.5% of the sample population was found to have dysphonia and 53.3% had glottic edemas. The ratio of GERD cases was 44.1%. With the presence of dysphonia, a significant difference was found in the grade of vocal cord edema, each score of acid reflux related to the symptoms of 3 out of 7 items, and the total score of the FSSG inquiry list.
The likelihood of edema of the vocal cords being found in cases having dysphonia was higher than in subclinical cases of sleep disorder patients, and acid reflux was recognized as a cause of dysphonia, as suggested from the questionnaire results.

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Initial thyroplasty type I was performed on five patients with high risk thyroid cancer who had resections to their recurrent laryngeal nerves due to invasion. The parients ranged from 75 to 87 years of age. The histopathology was anaplastic carcinoma in one patient and papillary carcinoma in the other four patients. Tracheocutaneous fistulae were found in four patients. Postoperative maximum phonation time was from 9 to 16 seconds. Postoperative aspiration was not observed in all cases. The four patients without anaplastic carcinoma lived without cancer for at least two years after their operations. Initial thyroplasty type I in conjunction with surgery for thyroid cancer is useful, but the indication of this procedure should be done with caution.

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Clinical investigations were performed on 129 cases that had been referred to our clinic with the complaint of foreign bodies in the throat between November 2006 and October 2007. Foreign bodies were found in 83 cases (64%) and the most common materials were fish bones (73 cases; 88%), notably eel bones. In children, most of the foreign bodies were fish bones in the oral cavity, in the palatine tonsil or at the root of the tongue. In the elderly, press through package (PTP) was considered to be another common material other than fish bones and was found mainly at root of the tongue, in the hypopharynx or in the esophagus. Most of the foreign bodies were easily removed under direct vision (87%) or under flexible endoscopy (7%). We had one patient with a self inserted acupuncture needle into supraglottic lesion that required direct laryngoscopy under general anesthesia to successfully remove the item. Our study suggests that age is an important factor to estimate the position of a foreign body. Although none of the non-detectable cases turned out to have a foreign body in an extrapharyngeal lesion in this study, we consider it important to perform the careful examination and intensive follow up of the patients even when foreign bodies are not detectable during their first visit.

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Microdissection technique under phonomicrosurgery with direct laryngoscopy was performed for 10 cases with shallow lesions resulting form early glottic cancer (8 with T1a and 2 with T1b). Type I cordectomies were performed for 9 cases and type II for 1 case.
Therapeutic outcomes showed 100% of local control rate during the follow-up periods from 6 months to 4 years. One case presented local recurrence which became well controlled by an additional microdissection procedure. Vocal outcomes indicated good preservation of vocal function in terms of maximum phonation time (MPT), mean flow rate (MFR), and acoustic parameters in most cases.
Microdissection technique has proved to be useful for definite local control of shallow lesions of early glottic cancer as well as for preservation of vocal functions postoperatively.

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We present a case of laryngeal granulomas in a 37-year-old pregnant woman. She complained of a change in voice quality, foreign body sensation, and recumbent dyspnea since the 6th month of pregnancy. She was found to have laryngeal granulomas in the posterior commissure, which obstructed her supraglottic space. We removed the larger granuloma under local anaesthesia at 7 months of pregnancy. After that excision, her dyspnea improved but the other symptoms remained. A month after the delivery, the other granuloma was removed with laryngomicrosurgery under general anaesthesia. In this case, the growth of laryngeal granulomas seemed to be related to the pregnancy.

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Injection laryngoplasy is one of the typical remedies for the treatment of glottal insufficiency. In Japan, silicone, collagen, autologous fat, and calcium phosphate cement have been used as injectable materials. No material, however, can fulfill all the ideal conditions such as biocompatibility, nonabsorbability, non-migrating, and ready formulation for easy injection.
Hyaluronic acid (HA) is one component of the extracellular matrix that plays a key role in tissue viscosity, shock absorption, wound healing, and space filling. Research into the role of HA in laryngology indicates that it has profound effects on the structure and viscoelastisity of vocal fold.
Injection laryngoplasty using HA was performed on a patient with glottal insufficiency. HA was injected into the vocal folds using an oral laryngeal injection needle in conjunction with laryngeal electroendoscopic observation under local anesthesia. The injection procedure was accomplished safely and no acute foreign body reaction was observed. Evaluations were made from the patient's subjective ratings, videostroboscopic examinations, and acoustical analyses. All of the postoperative results showed improvement when compared with preoperative status.
Injection laryngoplasty using HA could be one of the most suitable remedies for the treatment of glottal insufficiency.

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Two cases of laryngeal web were treated with laryngomicrosurgery. Laryngeal webs were cut off by KTP laser and silicon plates were placed at the anterior part of glottis. These silicon plates were fixed by nylon thread through the surface of the skin on the neck and were intended to be in place for three weeks.
Both cases had good outcomes in the improvement of their webs. The first patient had their silicon plate removed two weeks after the operation because they felt something wrong in the larynx. A knot of the thread through the neck skin had slid into larynx and the knot seemed to have stimulated the laryngeal mucosa.
The second patient's silicon plate came off the day after the operation. A follow up treatment was per-formed three days after defluxion. During this procedure, the plate was trimmed to nearly half its original size to prevent suffocation if the plate were to come off and heavier thread was used to avert thread breakage. Two knots were made concurrently at the top and bottom of silicon plate in order to avoid the thread sliding into the larynx. Three weeks after the first operation this second resized plate was re-moved.
Plate defluxion will cause death by suffocation. In first place, reliable fixation is desirable. Secondary, we should make all efforts to eliminate the possibility of suffocation if plate defluxion were to occur.

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A neurofibroma of the larynx is a rare disease that usually involves the arytenoids and the aryepiglottic fold. Treatment options for laryngeal neurofibroma are either the transoral or pharyngotomy approaches. The transoral approach had been indicated only for small tumor due to its limited operative field and difficulty in managing massive hemorrhaging. New device, such as the laser, distending laryngoscopy, videoendoscopy and special forceps enable us to resect larger tumors of the larynx.
Since laryngeal neurofibromas are benign tumor, transoral surgery could be the treatment of choice in order to reduce surgical invasion. We reported on a case of a huge laryngeal neurofibroma resected by a novel transoral approach. A five-year-old girl complaining of stridor and dyspnea and suffering from type 1 neurofibromatosis (von Recklinghausen's disease) was referred to our clinic. A tracheostomy and biopsy had already been performed at another institution. A flexible laryngoscopic examination revealed a 35 by 25 mm smooth pinkish mass covered by mucosa on the left arytenoid which was obstructing the airway. The left vocal cord was fixed and the right one was restricted by mass effect. The tumor was completely resected by the transoral approach. No intraoperaive and postoperative complications were noted. Oral intake commenced two days after the operation without swallowing disturbance. There was no recurrence of the tumor during a one year follow up and her tracheostoma was closed successfully.

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