Although widely used by patients who have undergone laryngectomy, vocalization using an electronic artificial larynx, tracheoesophageal shunt vocalization, and esophageal speech cannot reproduce a patient’s original voice, and this negatively affects their quality of life. In 2020, our department introduced a smartphone app called “coestation^®,” an AI-based software that can reproduce voices with great similarity to the patient’s original voice by synthesizing 200 voice-recorded sentences.

Our user survey revealed a high level of satisfaction with the similarity between the synthesized voices and the patients’ original voices. However, patients also showed dissatisfaction with the time lag and complexity of the app. In fact, only four of the six patients who agreed to participate in the survey were able to use the app properly. Consequently, the average voice-related quality of life among the app users was 61.9%, which is slightly lower than that among patients who used traditional substitute voices. Despite the remarkable quality of the voices reproduced by this innovative app, it should be constantly improved based on the patient feedback in order to meet their expectations.

When laryngectomy is performed for laryngeal or pharyngeal cancer, air from the lungs is expelled through the tracheostomy. The laryngeal primary tone, which is generated by the vibration of the vocal cords within the body, can no longer be produced, resulting in the permanent loss of the vocal organs. An electric larynx (EL) has been used as a means of communication for patients after laryngectomy since 1959. An EL is a cylindrical device that produces vibrations at the tip by pressing a button on its body. In other words, the device electrically produces a vibrating sound that replaces the original laryngeal sound. However, there are some problems: one hand is occupied when using the device, and only mechanical speech can be produced. Recently, a variety of devices have been developed to solve these problems. In this review, we will discuss hardware speech-assistive technologies, which we call speech-aid devices, including what they are and how they have been developed.

Loss of voice after total laryngectomy often prevents patients from reintegrating into society. This fact can also cause patients to be hesitant to undergo surgery. Therefore, the early introduction of alternative voice is essential for relieving anxiety and enhancing the rehabilitation of these patients. To achieve this, we introduced the following methods: interprofessional work (IPW) between doctors, nurses, and speech therapists; routine preoperative education for patients and their families; enhanced recovery after surgery (ERAS) with early consultation with a speech therapist; and appropriate device selection according to a patient’s condition.

The COVID-19 pandemic had a great impact on our rehabilitation program, and we responded to the changing environment to assure the early introduction of alternative voice.

In the treatment of advanced laryngeal or pharyngeal cancer, while progress has been made in larynx-sparing therapies such as chemoradiotherapy, induction chemotherapy, and partial laryngectomy, total laryngectomy still plays an important role in terms of local control and salvage surgery. The importance of rehabilitation after total laryngectomy has been recognized. Regarding voice substitution, it is important to select the most appropriate means in accordance with the patient’s social background and wishes, and we believe it is important that all facilities offer patients equal opportunities to choose. Although guidance on esophageal speech is often mainly provided by patient groups, it is becoming increasingly important to build partnerships not only with physicians but also with speech-language pathologists, nurses, physicians in charge of community medicine, caregivers, social workers, etc., in order to perform shunt speech. We believe that by successfully coordinating with multiple professions and reducing the burden on physicians, it will be possible to provide voice restoration in accordance with the patient’s wishes. We introduce the current status of voice restoration and explain the multidisciplinary efforts to select voice restoration in our department. We also discuss our attempts to provide voice therapy for patients with shunt dysphonia.

The standard treatment for advanced laryngeal cancer is total laryngectomy and chemoradiotherapy, but measures against adverse events vary. Complications such as pharyngocutaneous fistula after total laryngectomy can be prevented to some extent by the preoperative and intraoperative efforts of the otolaryngologist, and it is necessary to improve the skills of surgical techniques. The incidence of pharyngocutaneous fistulas at our facility was 20.3% (53/261) over 20 years, with a significant reduction in fistula incidence from 31.5% in the first decade to 10.2% in the second decade (p=0.000024). Preventive measures against pharyngocutaneous fistulas include appropriately trimming the margins of the pharyngeal mucosa with an impaired blood flow, making drugs with antibacterial activity against oral anaerobic bacteria the first choice as a prophylactic antibacterial drug, and performing pharyngeal closure using the Gambee stitching method. Thanks to these efforts, other than salvage surgery after chemoradiotherapy, only 2 out of 34 cases developed pharyngocutaneous fistulas, both of which were cured by conservative treatment; however, in salvage surgery after chemoradiotherapy, pharyngocutaneous fistulas were seen in 3 out of 10 patients, all of which required surgical treatment. Regarding adverse events of chemoradiotherapy, multidisciplinary supportive care is essential, and otolaryngologists are required to take on a leadership role in organizing teams capable of performing specific interventions.

This study examined the adverse events associated with advanced laryngeal cancer treatment in International Medical Center Saitama Medical University and described the countermeasures taken. During chemoradiotherapy, special attention should be paid to patients to prevent the need for discontinuation of CDDP due to renal dysfunction. Regarding surgical cases, cases of minor leak were relieved by conservative treatment, but leak cases despite small fistula in the super-elderly were long delayed in wound healing. Although no significant difference was observed in the suture shape of the pharyngeal mucosa itself, it is considered essential to optimize the wound healing mechanism by ensuring a sufficient blood supply.

Postoperative pharyngocutaneous fistula after head and neck surgery is a devasting complication that increases hospitalization time and delays the initiation of oral intake and postoperative adjuvant therapy. Although it is commonly experienced, the treatment strategy differs greatly according to the size and site of the fistula and the preference of the surgeon, and a standard therapy remains to be established.

Since it was first reported in 1997, negative pressure wound therapy (NPWT) has been widely applied in the treatment of complicated intractable wounds all around the body. However, its use in the treatment of head and neck fistulas has been less frequent because of the numerous undulations of the skin on the surface of the head and neck, which make an airtight seal difficult to achieve. In addition, salivary contamination and possible air leakage from the fistula are major obstacles in applying NPWT to head and neck fistulas.

We have actively applied NPWT in the management of head and neck fistulas and have successfully treated these complicated wounds. Thorough wound bed preparation and the application of hydrocolloid materials around the wound edge have enabled the continuation of NPWT without leakage and infection. Incisional drainage performed a small distance from the location of the fistula was helpful for avoiding leakage during NPWT.

In this article, we present our current treatment strategy utilizing NPWT for head and neck fistulas and delineate the tips for avoiding leakage during NPWT.

Dysphagia is a late adverse event of radiotherapy with concomitant Cisplatin (CDDP-RT), and patients with advanced laryngeal cancer who undergo CDDP-RT have an impaired swallowing-related quality of life. Dysphagia induced by CDDP-RT has two major causative factors: delayed or untimely swallowing reflexes caused by xerostomia or oral or oropharyngeal mucosal sensory disturbance and a decrease in laryngeal perception, laryngeal elevation disorder, inadequate relaxation of the cricopharyngeal region, and other problems with the swallowing function due to the effects of RT on the larynx, pharyngeal contractile muscles, and other parts of the neck. Oral healthcare and dysphagia rehabilitation are considered essential for patients requiring CDDP-RT, and such a support system needs to be established at the facility in question. Future clinical trials (JCOG1912) will help clarify whether or not reducing the dose in the prophylactic irradiation area can mitigate late adverse events while maintaining treatment efficacy. Induction chemotherapy may be able to reduce the extent of irradiation of the tumor area and the area of prophylactic irradiation. However, this has not yet been proven, and further studies in larger cohorts are needed.

We conducted a non-randomized retrospective study of the treatment of locally advanced head and neck squamous-cell carcinoma (LA-SCCHN), comparing induction chemotherapy (ICT) with cetuximab plus cisplatin and fluorouracil (FPE) with docetaxel plus cisplatin and fluorouracil (TPF), followed by radiotherapy with cetuximab. We non-randomly assigned 24 patients (all of whom had N stage N2 or N3 with no distant metastases and were candidates for organ preservation) to receive either FPE- or TPF-ICT, followed by radiotherapy with cetuximab. We evaluated the efficacy and safety. The overall response rate, one-year progression-free survival, and one-year overall survival were comparable between the FPE and TPF arms. Hematological toxicities during ICT were more pronounced in the TPF arm than in the FPE arm. No grade 4 or 5 adverse events were observed in the FPE arm. Patients with LA-SCCHN who received FPE-ICT had a comparable efficacy and fewer hematological toxicities compared with patients who received TPF-ICT. FPE-ICT may be a viable alternative to standard TPF-ICT for the treatment of LA-SCCHN.

The Departments of Psychiatry Neurology, Gynecology, Urology, and Plastic and Reconstructive Surgery play a central role in the operation of the Okayama University Gender Clinic. At the Gender Clinic, physical treatments such as hormonal therapy and surgical therapy for gender dysphoric people are performed in accordance with “The diagnostic and therapeutic guidelines for patients with gender identity disorder (The Japanese Society of Psychiatry and Neurology)”. The motivation for seeking these treatments is the strong discomfort arising from having physical characteristics opposite to one’s own experienced gender. The dysphoria experienced by the person involved stems from both a subjective sense of discomfort and a suspicion that others may be uncomfortable with an appearance that does not resemble the desired gender. This is because when the individual is certain that they perceive themself as male (female) and at the same time are certain that those around them perceive them as male (female), they will be insecure when acting as a male (female) in society. This situation is not only insecure but also leads to disadvantages in social life. Mastectomy, facial feminization, masculinization or feminization of appearance through hormone therapy, etc., and female voice through vocal cord surgery are thought to improve subjective gender discrepancy and at the same time improve social discomfort and reduce disadvantages in daily life. Of course, we must not forget that the essential solution is to create a tolerant society that accepts a person in the gender that they desire, no matter what their appearance may be.

Male to female gender identity disorder (MTF/GID) is a rare condition. Such patients tend to complain that their speaking fundamental frequency (SFF) does not fit because it is too low. Type 4 thyroplasty (TP4) conversely increases the pitch of the SFF as the tension of the vocal fold is tightened causing the SFF to become high-pitched. While vocal pitch disorder is not life-threatening for patients with MTF/GID, it can cause substantial worry and stress. TP4 can therefore improve the quality of life of patients with MTF/GID.

Trans men are biological females who have a male identity and have a sense of discomfort with their own feminine physical characteristics. The administration of testosterone, a male hormone, for the treatment of gender incongruence induces physical masculinization, including changing the sound of the voice. We previously showed that continuous administration of testosterone lowered the basic frequency (F0) and masculinized the voice abruptly at three to six months from the treatment onset. We therefore examined and compared the voice changes in patients and their feelings of discomfort with their voice using the voice handicap index (VHI) before and after testosterone administration. We also compared these findings with the VHI scores of trans women before intervention. The VHI scores of trans men were lower after testosterone administration than before and not significantly different from those of a control group without voice disorder. Trans women were found to have a stronger feeling of discomfort with their voice before intervention than trans men, which may be why most individuals who receive voice treatment are trans women.

In female-to-male/gender identity disorder (FTM/GID) patients, no voice therapy (VT) is required, as the administration of male hormones will naturally cause the voice to become low-pitched. However, in male-to-female (MTF)/GID patients, the administration of female hormones does not cause the voice to become high-pitched. Since 2014, we have performed type 4 thyroplasty (TP4) and preoperative and postoperative VT for MTF/GID patients. In this study, we examined the outcomes of VT. The speaking fundamental frequency increased, while the functional and physical points on the Voice Handicap Index (VHI) decreased slightly, and the emotional points on the VHI significantly decreased. Postoperative complaints included difficulty speaking, difficulty passing as female, and a different subjective image of their eventual female voice. The importance of preoperative and postoperative VT was reconfirmed. However, it is also important for these patients to learn how to speak, how to dress, and how to wear make-up.

Arytenoidectomy, or the partial removal of the arytenoid cartilage, is a surgical procedure performed to treat bilateral vocal fold immobility. It can widen the posterior glottis, which is important as an airway, and maintain the voice quality more effectively than vocal fold lateralization. In addition, it is expected to have a permanent effect without the possibility of relapse due to the breakage of traction threads or subsequent infection. When the opening of the glottis is insufficient after arytenoidectomy for posterior glottic stenosis, vocal fold lateralization should be additionally performed.

Glottal airway enlargement is required to manage dyspnea due to bilateral vocal fold paralysis (BVFP). The method of vocal fold laterofixation reported by Ejnell et al. is relativly non-invasive and has been considered the first choice in cases of BVFP in recent years. We used a video-laryngoscope to obtain a better endolaryngeal view and a GORE-TEX^® Soft Tissue Patch as a spacer between the thyroid lamina and the nylon knot to prevent loosening. Laryngeal pacing is a more dynamic and physiologic treatment approach than static airway enlargement procedures, such as laterofixation of the vocal fold. Laryngeal pacing is the application of functional electrical stimulation (FES) of the laryngeal abductor muscles. We evaluated the efficacy of FES in restoring glottal opening, ventilation, and exercise tolerance in a BVFP canine model. An implantable stimulator and deep brain stimulation electrodes were surgically implanted into both posterior cricoarytenoid (PCA) muscles in the animal, and the bilateral recurrent laryngeal nerves were sectioned and repaired. Beyond three months postoperatively, there was passive airway narrowing and further closure of the glottis during hypercapnia. The animal showed severe stridor and could only walk for one to two minutes on a treadmill. With the stimulation-on condition, the glottal area increased considerably, equaling that of a normally innervated animal. Exercise tolerance also returned to normal. Bilateral PCA stimulation offers a physiologic approach to restore ventilation to a normal level in cases of BVFP.

Laryngeal web most frequently occurs due to acquired rather than congenital factors. It can cause dysphonia and airway disorder depending on the extent of the area or thickness of the web. The prevention of relapse after web resection is the most important aspect of surgery for laryngeal web. A local mucosal flap can be developed using the superior and inferior surface of the web. This flap can cover at least one side of the wound on the vocal fold after web resection, and consequently leads to primary healing. The other technique for preventing web relapse is to place a stent (also called a “keel”) at the anterior commissure after removing the web. A slim silicone tube can be used as a stent to prevent web relapse. A membrane like plate can also be adopted. The round-shaped silicone tube has an advantage in softness for the vocal fold in comparison to a flat-shaped plate. One of the disadvantages of the silicone tube is that it cannot cover the wound that develops after the resection of a broad web affecting the posterior membranous vocal fold. To resolve this problem, we developed a new type of silicone stent that includes both a tube and a plate component. An appropriate surgical method and stent should be chosen based on the condition of the web.

Vocal fold paralysis and arytenoid dislocation are the differential symptoms for unilateral vocal fold movement disorder. However, their diagnosis is difficult. To diagnose dislocation, it is necessary to understand the movements characteristic of unilateral fold paralysis. A particularly important finding of paralysis is the passive gliding movement that is displaced in the cranial direction during phonation. The presence of this movement is diagnostic of paralysis rather than dislocation. A number of previous reports on dislocation have diagnosed the presence of this passive movement as dislocation. In Japan, the term ‘fixation’ is often used to describe the position of the paralyzed vocal folds, as in ‘mid-position fixation’ or ‘sub-median fixation’. There seems to be a misconception that ‘paralyzed vocal cords are immobilized’. In the case of dislocation, by contrast, the muscular process is unable to move beyond the midline of the articular surface, and the movement of the arytenoid is severely restricted and immobile. It has been misunderstood that immobility is paralysis while wobbling is dislocation. However, paralysis is the presence of wobbling movement (passive gliding movement), and dislocation is immobilization and inability to move. Dislocations have previously been divided into two categories of anterior and posterior dislocations, but vertical dislocations have not been mentioned. In past reports, the terms ‘anterior’,‘posterior’,‘medial’, and ‘lateral’ have been used to refer to the position of dislocation. However, these terms do not indicate the position in the vertical direction. We divided the cricoid facet into four areas: mediocaudal, laterocaudal, mediocranial and laterocranial. We published on recurrent adductor branch paralysis in 2010. Gradually, the concept of partial laryngeal palsy has become more widespread. Looking at previous reports, adductor branch paralysis may have been included in many studies diagnosing posterior dislocation (mediocranial). Understanding the characteristics of adductor branch paralysis is crucial. It is important to understand the three-dimensional arrangement of the arytenoid cartilage for the diagnosis of unilateral vocal fold movement disorder and clarifying the characteristics of paralysis.

Vocal fold scars and sulcus cause severe vocal problems, but no optimal treatment has been established. In severe cases, in which the entire lamina propria is occupied by severe fibrosis and the vibratory function is completely lost, more powerful regeneration materials should be used, or the mucosa should be totally replaced. Amniotic membrane is a scaffold material that is rich in stem cells and growth factors and has a high regenerative effect. It can be clinically applied in many fields. Several studies have already investigated the effects of amniotic membrane on the vocal fold in animal studies. These studies have shown that the amniotic membrane is effective for vocal fold regeneration. In particular, our study showed that the transplantation of an amniotic membrane to the rabbit vocal fold induced high hyaluronic acid retention and the suppression of collagen deposition after three months without rejection. We hope that the use of the amniotic membrane for vocal fold regeneration will be broadly applied in the future.

Purpose : Ossification of the laryngeal cartilage has been investigated, including the pattern of ossification, age-related changes, and sex differences. This study aimed to examine the beginning, the processes, and sex differences of ossification of the laryngeal cartilage in Japanese patients using ultra-high-resolution computed tomography (UHRCT).

Materials and methods : A total of 47 cases were included in the present study (male, n=34 ; female, n=13). UHRCT was performed, and ossification of the laryngeal cartilage was visualized in three-dimensional (3D) images. Reconstructed images were evaluated the degree and process of ossification of laryngeal cartilage was compared between males and females in various age groups.

Results : In both sexes, ossification of the thyroid cartilage started at less than 20 years of age. The pattern of thyroid cartilage began in the inferior horn, and spread upward in the superior horn and extended toward the midline along the inferior borders, ending at the lamina. The beginning part in cricoid cartilage was the cricoarytenoid joints, and that in arytenoid was muscular processes. On UHRCT, ossification of the laryngeal cartilage characteristically showed a “figure 8 of thyroid laminae” sign that was constructed by the paramedian bar and two rounded non-ossified areas.

Conclusion : Ossification of the thyroid cartilage began at <20 years of age. The degree of ossification of the thyroid cartilage will increase with age ; however, the degree and frequency of the ossification in males greater in comparison to females. Three-dimensional images allowed the evaluation of ossification of the laryngeal cartilage.

Patients with disabilities and those receiving medical care at home may be vulnerable to disasters, as they may not be able to evacuate quickly in the event of a large-scale disaster. A questionnaire survey was conducted among patients and their families under home tracheostomy management regarding preparedness for a major disaster, evacuation, and equipment needed in evacuation centers with the aim of identifying current conditions and problems in the event of a major disaster. A total of 34% of respondents answered that “family members can evacuate by themselves,” while 33% answered that “assistance is necessary,” and 33% answered that “evacuation is not possible,” indicating that most patients could not evacuate by themselves should a disaster occur. Although 87% had prepared the supplies necessary for tracheal cannula management in case of a disaster, respirator batteries were the most frequently reported equipment needed in evacuation centers. Evacuation decisions and methods were major concerns faced by patients and families. In terms of disaster preparedness, a community-wide effort involving not only medical institutions and local governments but also providers of medical services is considered important.

We herein report a rare case of thyroid chondrosarcoma in which laryngeal preservation surgery was performed. The patient was a man in his 40s. A hard mass was palpated on the right lateral side of the thyroid cartilage. Enhanced computed tomography showed a tumor on the right lateral side of the thyroid cartilage with partial destruction of the thyroid cartilage. Ultrasonography-guided fine-needle aspiration cytology suggested the lesion was a tumor of cartilage origin. We therefore diagnosed a thyroid cartilage tumor. We performed partial laryngectomy. Intraoperative findings revealed a hard tumor contiguous with the thyroid cartilage deep in the right omohyoid muscle. The right two-thirds of the thyroid cartilage were cut longitudinally, and the tumor was removed. The pathological diagnosis was a grade 2 chondrosarcoma of thyroid cartilage origin. Two years after surgery, there was no recurrence. There have been 37 cases of laryngeal chondrosarcoma reported in Japan, and only 8 were of thyroid cartilage origin. Surgical treatment was selected in all cases, with 16 cases treated by total laryngectomy and 21 cases by partial laryngectomy. Recurrence was reported in five cases, including local recurrence in three cases, cervical recurrence in one case, and distant metastasis in one case.

A one-year-old boy accidentally aspirated a salmon bone while eating. Computed tomography showed a foreign body at the larynx level, and a fiberscopic examination revealed a fish bone in the glottic space. The first attempt to remove the foreign body by forceps using laryngoscope failed with the child conscious. This treatment caused laryngeal edema, and tracheostomy was performed. The foreign body was ultimately removed using a direct laryngoscope under general anesthesia. Children who have aspirated a foreign body in their larynx may have a variety of symptoms, such as mild irritation, cough, and respiratory distress. The diagnosis of this condition demands a high degree of suspicion, since a physical examination and symptom-based evaluation have low sensitivity. Clinicians should be more alert for this condition at the initial presentation. Laryngeal foreign bodies occasionally require removal via tracheostomy because children have small airways and choke easily. Tracheostomy should be performed when a risk of choking during or after treatment is expected.

Posterior glottic stenosis (PGS), of which the most common cause is tracheal intubation, is often misdiagnosed as bilateral vocal cord paralysis. We herein report a case of PGS that occurred after treatment with COVID-19 with long-term intubation. The patient underwent tracheostomy and endoscopic resection and showed improvement in dyspnea. The COVID-19 epidemic is expected to increase long-term intubation cases and cases of severe laryngeal injury, including PGS. We need tracheostomy in long-term intubated COVID-19 patients, just like other diseases, and an appropriate diagnosis and surgical treatment for PGS should be performed. When otolaryngologists encounter cases of bilateral vocal cord paralysis, it is necessary to keep in mind the possibility of PGS and laryngeal stenosis and pay attention to the history of COVID-19.