We describe herein a case of acute oropharyngeal palsy (AOP), a rare subtype of Guillain-Barre syndrome (GBS). After the initial report of 3 AOP cases by O'Leary et al. in 1996, several other cases have been reported, but no disease concept, diagnostic criteria, or treatment have been established. Furthermore, there has been no report of AOP in the otolaryngology literature. A 16-year-old male presented with initial symptom of palatoplegia characterized by poor lifting of the bilateral soft palates, rhinolalia aperta, and slight loss of pharyngeal reflex. Acute development of peripheral nerve disease and a GBS subtype were suspected. Diagnosis of AOP is based on the presence of anti-ganglioside antibodies and elevation of anti-GQ1b-IgG and anti-GT1a-IgG antibody levels. The anti-GQ1b-IgG antibody level was (2+), the anti-Ga1NAc-GD1a-IgM antibody level was (2+), the anti-GT1a-IgM antibody level was (1+), and the IgG antibody level was (2+). Other antibodies were negative. Based on the clinical symptoms, course, and antibody test results, the patient was diagnosed as having AOP. The symptoms gradually improved over the time course with observation alone and disappeared after about one month. The findings of this case suggests that subtypes of GBS should be considered in an oropharyngeal examination. Otolaryngologists who routinely perform oropharyngeal examinations should take the subtype diseases of GBS into consideration as a potential cause of acute development of rhinolalia aperta and nasopharyngeal reflux.
We clinically examined 165 cases (86 men and 79 women) with major salivary gland tumors who were treated at our hospital (parotid gland: 131 cases, submandibular gland: 32 cases, sublingual gland: 2 cases) between January 2002 and December 2015. The mean age of the patients was 58.7 years (parotid gland: 58.3 yo, submandibular gland: 59.8 yo, sublingual gland: 69.5 yo). Histopathologically, there were 143 cases (86.7%) of benign tumors and 22 cases (13.3%) of malignant tumors. The most frequent type of benign tumor was pleomorphic adenoma, followed by Warthin's tumor. There was no case of Warthin's tumor in the submandibular gland. On the other hand, the most frequent type of malignant tumor was adenoid cystic carcinoma, followed by malignant lymphoma and adenocarcinoma (NOS). Rates of the malignant tumors in the parotid, submandibular and sublingual gland were 7.6%, 31.3% and 100%, respectively. One hundred sixty-three patients underwent surgery. Five cases of malignant lymphoma were additionally treated in the Department of Internal Medicine. Nine cases had adjuvant radiation therapy and 8 cases had adjuvant chemotherapy. Postoperative complications were facial nerve palsy in 14 cases, salivary fistula in 7 cases and Frey's syndrome in 2 cases. Five-year disease-specific survival rates in 17 cases of malignant tumors were 73.7%.
Many hospitals perform open gland excision to treat submandibular hilar stones and some hospitals perform sialendoscopic surgery. Open gland excision is relatively invasive for salivary calculi, and sialendoscopic surgery requires a neodymium-yttrium aluminum garget (ND-YAG) laser system which is very expensive. Transoral surgery is less invasive than open gland excision and requires no expensive instruments. We performed transoral surgery for submandibular hilar stones in 15 patients with 16 sites. Removal of the stones was successful in all patients, accompanied with several short-term complications such as slight fever (9 patients), submandibular swelling (12 sites), lockjaw (3 patients), lateral pharyngeal edema (1 patient) and slight laryngeal edema (1 patient). All the short-term complications were transient and there was no significant long-term complication. Transoral surgery for submandibular hilar stones is a minimally invasive, safe and cost-effective operation.
We previously generated a rat model of gastroesophageal reflux disease (GERD) and observed the histological changes caused by gastric acid reflux in the pharynx, larynx and respiratory tract. In present study, we report on pathological changes in the tooth and pharynx of the GERD rat models. At 10 weeks after surgery, heights of dental crowns were shorter in the GERD rat models than in the control rats, and inflammatory cell infiltration by gastric acid reflux were found in the periodontal mucosa. Furthermore, dental erosion had progressed in the GERD rat models at 20 weeks after surgery, demonstrating both enamel erosion and exposure of the dentin. During the same period, inflammatory cell infiltration was observed in the mucosa of the posterior part of tongue. This result suggests that gastric acid reflux may be one of the exacerbating factors of dental erosion, periodontitis, and glossitis.
[Introduction] Streptococcal toxic shock syndrome (STSS) is an infection with a very high mortality rate. We report herein on the occurrence of STSS in the head and neck, the 15th case of STSS in Japan. [Case] The patient was a 46-year-old male. One day after performing curettage for a rash in the right submandibular region, a swelling appeared in the neck and he was brought to our department as an emergency patient on the 2nd day. Vital signs were indicative of shock when he was brought in and a marked inflammatory response with acute renal failure were observed. CT showed inflammation of the skin and soft tissue extending from the neck to the anterior thoracic region and gas shadows in the anterior mediastinum, and a diagnosis of septic shock accompanied by cellulitis of the neck and mediastinitis was made. We performed a mediastinotomy via the neck with a tracheotomy, and administered PIPC/TAZ. In a culture specimen obtained from the operative field, Group A β-hemolytic streptococcus was detected and soft tissue necrosis and disseminated intravascular coagulation were present, leading to a diagnosis of STSS. The patient was managed in the ICU and on day 4 after developing STSS, it abated. On day 35 post-surgery, debridement was performed under general anesthesia and on day 100 the patient was discharged. [Conclusion] The patient's life could be saved through prompt administration of antibiotics and surgical actions as well as appropriate intensive care. STSS is a rare condition but we must still keep it in mind.
Abstract: Sialodochitis fibrinosa (sialodochitis fibrinous or fibrous sialodochitis) was first reported by Kussmaul in 1879, and is characterized by recurrent salivary gland swelling and mucofibrinous plugs or jelly like saliva from the salivary ducts. The plugs and saliva are rich in eosinophils and the condition is often complicated with allergic diseases. Sialodochitis fibrinosa is considered to be an allergic disease and in some reports is called allergic parotitis. We report herein on an infant case of sialodochitis fibrinosa. A 7 years old girl with bronchial asthma suffered from submandibular swelling after meals. Her saliva was rich in eosinophils and one day eosinophil-rich mucofibrinous plugs was discharged from her Wharton's duct. Her blood eosinophil ratio was slightly high at 7.4%. Sialography documented narrowing of the Wharton`s duct and unclear images of the submandibular gland. With anti-histamine drug treatment, her submandibular gland swelling gradually improved. There has been no case report of sialodochitis fibrinosa in an infant before 2003.
A total of 24 patients with palmoplantar pustulosis who underwent tonsillectomy at the Otolaryngology Division, Kochi Health Sciences Center between March 2005 and March 2016 were assessed for gender, first-onset age, age at the time of tonsillectomy, smoking status, and postoperative outcome, and discussed for recurrence factor.
The study population comprised 3 males and 21 females with a mean first-onset age of 37.8 years and a mean age at the time of tonsillectomy of 45 years. The smoking status at the time of first visit was as follows: 15 smoking patients, 4 patients abstaining from smoking, and 5 non-smoking patients. From among those whose skin symptoms were relieved, two patients visited our division with recurrent skin symptoms and were immediately referred to the Dermatology Division and the Dentistry Division. To date, 6 years following the recurrences, their skin symptoms persist, although the severity is mild.
The post-remission recurrences observed suggest a possible shift of causal factors of palmoplantar pustulosis from the palatine tonsil to other sites of the body after tonsillectomy. The high percentage of smokers suggests that smoking may be associated with the pathogenesis and causal factor shift in the disease.
Nasal continuous positive airway pressure (NCPAP) is considered the gold standard and the primary treatment for obstructive sleep apnea (OSA), however surgery is also carried out aggressively in the worldwide. Most of the OSA patients have single-level narrowing site, but there are few patients with multilevel narrowing sites. We evaluated the efficacy of therapy and complications after combination surgery, uvulo palato pharyngo plasty (UPPP) plus lingual tonsillectomy (LT) for OSA.
UPPP and LT were undertaken in 19 patients with moderate and severe OSA between 2012 and 2016. The Epworth Sleepiness Scale (ESS) score, polysomnography and the incidence of complications were used for the evaluation of surgical outcome. The mean ESS score decreased significantly. The mean apnea-hypopnea index (AHI) improved. The sleep efficiency, rapid eye movement, stage 1 and stage 2 sleep also improvement significantly. As postoperative early complications, there were many cases of epiglottal swelling and pharyngeal discomfort, and four cases of taste disturbance occurred one month postoperatively. Combination surgery is effective for multilevel OSA allowing sites but it is important to predict the postoperative complications.
Recently, fractionated exhaled nitric oxide (FENO) is being clinically used as a marker for disease diagnosis or an activity indicator for airway inflammatory diseases such as asthma. FENO reflects nitric oxide (NO), which is released from the airway epithelium, especially the paranasal sinus, due to upper airway inflammation and oxidative stress. Therefore, FENO is also associated with NO levels in the nasal cavity. Obstructive sleep apnea syndrome (OSAS) is caused partly due to nasal obstruction and fluctuation of the airflow, suggesting that FENO, especially nasal cavity NO, could be associated with the clinical condition in patients with OSAS.
In this study, we evaluated nasal cavity NO for 68 patients suspected of having OSAS. We measured both nasal FENO and oral FENO and defined the nasal cavity NO as the difference between the two (nasal FENO-oral FENO).
Nasal cavity NO levels were significantly elevated in patients with severe OSAS (respiratory event index of 30 or more) and reduced after continuous positive airway pressure therapy.
These findings indicate that nasal cavity NO levels might be linked to the condition of patients with OSAS and might be clinically used as a marker of disease activity.
Tumors of the base of the tongue have been removed through various surgical approaches. We herein report a case of schwannoma of the base of the tongue in which the tumor was removed by endoscopic laryngo-pharyngeal surgery (ELPS). An asymptomatic 39-year-old man in whom a tumor of the base of the tongue had been incidentally discovered when he was admitted to the outpatient clinic. A smooth surface tumor was found on the base of the tongue by laryngoscopy. PET-CT revealed that the tumor was exophytic and it was diagnosed as benign. Two years later, the patient became aware of dyspnea and pharyngeal discomfort and visited the outpatient clinic again, and the tumor was found to have been growing. The tumor was removed by ELPS. It was possible to resect the tumor safely without cutting deep into the muscular layer. There was little bleeding during the operation. The tumor, which was 3.0×2.5×2.5 cm in size, was histopáthologically diagnosed as a schwannoma. The patient had no neurological paralysis after the operation. ELPS proved to be a good surgical technique for resecting an exophytic tumor of the tongue base.
Oral aphthous ulcers are mostly caused by infection. However, it could be one of the symptoms of an auto-immune disease. We report herein on a 16-year-old male who presented with multiple oropharyngeal aphthous ulcers and was finally diagnosed as having incomplete Behçet's disease. Behçet's disease is a chronic inflammatory disease with prominent symptoms, including recurrent oral aphthous ulcers, cutaneous and ocular manifestation, and pudendal ulcers. This disease should be suspected when patients have a high fever, sore throat and oropharyngeal aphthous ulcers that fail to respond to antimicrobial agents but do respond to steroid treatment. Early diagnosis in collaboration with other clinical departments is preferable because patients who have uveitis often lose their eyesight.
We often have difficulty when diagnosing the origin of soft palate perforation and many diseases induce soft palate perforation. We report herein on a 35-year-old woman with left otalgia, left hearing loss and soft palate perforation due to tuberculosis. She had consulted a nearby ENT doctor with left otalgia and left hearing loss and was diagnosed as having otitis media. Antibiotics were prescribed, and during the course of antibiotics, the patient had a soft palate perforation. She was referred to our hospital for further treatment after adrenocorticosteroid administration for a few weeks. Cultures of sputum and otorrhea were negative. Although Chest CT scan showed micronodules and bronchial wall thickening, the T-SPOT TB test was not positive because she had been taking adrenocorticosteroids. Mycobacterium tuberculosis was finally isolated in respiratory samples obtained by fiberoptic bronchoscopy. Antituberculous therapy was administered for over 10 months, and during that time, the symptoms regressed and then, disappeared. At the 18 months follow-up, no recurrence was observed.
Patients with soft palate perforation should be investigated in more detail before therapy for soft plate perforation and tuberculosis should be considered in the differential diagnosis, especially if immunosuppressive treatment had been administered.
According to various reports, post tonsillectomy hemorrhage (PTH) rate widely ranges up to 50%. In general, it is higher in hot knives use, particularly ultrasonic scalpel. There are few ideas on ways to reduce secondary PTH.
In our study, we included slight bleeding episodes 24 hours after tonsillectomy as secondary PTH, and estimated secondary PTH rate by ultrasonic scalpel at 45.8%
So we administered tranexamic acid for 12 days after tonsillectomy. This helped in significantly lowering the secondary PTH rate to 8%
Given the results, our study strongly suggests the administration of 12 days tranexamic acid after tonsillectomy for secondary PTH as prophylactic treatment.
Carotid body tumor is a paraganglioma that develops from carotid artery corpuscles, and surgical treatment is required for radical cure. It is a disease that is difficult to deal with because it involves risk of bleeding from the tumor, carotid artery injury, subcranial neuropathy. We reported that it was safe to perform ablation using ultrasonic energy device and blood vessel micro clip in a relatively short time. A case was a 38-year-old female. The chief complaint was left cervical swelling and was introduced to our department for the purpose of review. Contrast CT, contrast MRI and neck ultrasonography revealed that there was a tumorous lesion with a maximum diameter of 48 mm on the bifurcation of the left carotid artery, which was polyhomogeneous and non-uniformly contrasted. We diagnosed it as a carotid body tumor. Distant metastasis was not observed with chest abdominal contrast CT. As a result of Balloon Matas test, no cranial nerve symptoms were observed. Surgical excision was chosen.
Angiography was performed on the day of surgery, and significant carotid angiography revealed marked tumor contamination. We embolized the main feeder, the ascending pharyngeal artery. The tumor surrounded the left internal carotid artery and the external carotid artery and was Group III of the Shamblin class. Despite embolization, the external carotid artery was dissected because of the abundance of nutrient blood vessels from the external carotid artery system. However, bleeding could be controlled by using an energy device. The operation time was 3 hours 52 minutes and the bleeding volume was 322 ml. Postoperative brain neurological symptoms were recognized. In this case, it was possible to perform surgery with safe and relatively small bleeding by using energy device and blood vessel micro clip.
[Introduction] Lemierre syndrome is characterized by four points as follow a preceding anaerobic infection of the pharynx; sepsis; a thrombus of internal jugular vein; and metastatic infection to the lungs and joints. Many cases are caused by the bacterium Fusobacterium necrophorum. The morbidity rate of Lemierre syndrome is 0.6-2.3 per one million, but its mortality rate is 4-22%. We report herein on a case of Lemierre syndrome. [Case] A 21-year-old man was aware of fever and right pharyngalgia. After several days, he had disturbance of consciousness and was brought to our hospital. His vital signs were indicative of shock when he was brought in and a marked inflammatory response was noted. CT imaging showed a thrombus of the internal jugular vein, inflammation of the skin and soft tissue of the right neck, right neck lymphadenitis and right pyothorax. Blood culture revealed F.necrophorum. His diagnosis was Lemierre syndrome. After admission, antibiotics and an anticoagulant were administered. He gradually recovered, and was discharged after 63 hospital days following admission, Antibiotics were discontinued 31days after discharge, followed by the anticoagulant at 38 days. He is currently disease-free. [Conclusion] Lemierre syndrome is a rare disease, but its mortality rate is very high. So, as any delay in the diagnose could have fatal consequences. We should be careful in our daily examination.
As a definitive treatment for pyriform sinus fistula, open neck surgery has been the basic surgical procedure of choice, and recently some facilities have additionally reported transoral endoscopic chemocauterization. We report herein two cases of pyriform sinus fistula including a case in an infant, in which resection was performed with transoral videolaryngoscopic surgery (TOVS), originally developed for laryngopharyngeal cancer resection.
The advantages of TOVS are that we ensure complete closure of the route of infection by resection of the fistula tract and suturing of the mucosa, and it is a less-invasive treatment using transoral techniques without any skin incision. Moreover, we can identify the orifice of the fistula tract and perform the surgery without difficulty, even in cases complicated with severe scar formation in the neck. Although this method has been adapted for short fistula tract cases, it can be performed not only in adults but also in infants.
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