In Japan, there are few medical institutions which have sleep medicine as a speciality, and the role of the general hospital is large. The medical examination and hospital and clinic cooperation are herein described, which are expected of the general hospital which does not specialize in make sleep medicine. In an adult, an exact morphological diagnosis including sleep study and indication of pharyngeal surgery is important. In the case of a child, it is similar, but, in adaptation of medical treatment, greater importance is attached to the clinical symptoms than in an adult. Also in those patient for whom surgery is not indicated, when there is SDB condition, prudent medical follow-up is required. When any complication associated with sleep disorder is suspected, cooperation with a specialized sleep clinic is required. A safe and high-standard hospital environment with clinical cooperation is recommended for sleep medicine.
The patient was a 30-year-old man who had become aware of a mass in his left cheek around the age of 17. He consulted our department after noticing that the mass was gradually increasing in size. We noted a fist-sized mass with limited mobility in the anterior portion of the left ear and following various examinations, we suspected a primary malignant tumor of the accessory parotid gland. No apparent lymph node metastasis or distant metastasis was observed, and surgery involved left parotidectomy, resection of the skin and parotid gland, and left neck dissection. Thereafter, we reconstructed the buccal branch of the facial nerve with the great auricular nerve and closed the skin defect with a rotation-advancement flap. A postoperative pathological examination led to a diagnosis of mammary analogue secretory carcinoma with sarcomatoid change. The patient underwent subsequent chemoradiotherapy, but experienced recurrence and repeat metastasis and died 15 months postoperatively.
We report herein on a case of a large intraoral mature teratoma, progressing into the skull base. A 39-year-old woman in her second pregnancy was referred to our hospital, due to a facial tumor in the fetus identified with ultrasonography. Fetal magnetic resonance imaging (MRI) was performed in order to make an adequate diagnosis. It showed a large cystic intraoral tumor which infiltrated the skull base. However, we assumed that the fetal airway was maintained because polyhydramnion was not observed. In the 38 th week of pregnancy, a caesarean section was attempted. Just after the birth, upper airway obstruction occured provoked, and we needed airway management. As the large mass increased gradually, partial resection was undertaken. Pathologically, the tumor was found to be mature teratoma. As imaging modalities have further improved, prenatal consultations with pediatric otolaryngologists are increasing. Fetal MRI is very useful, though it is necessary for us to consider that the situation may change along with the passage of time.
Recently it becomes clear that cetuximab with radiotherapy is useful for locoregionally advanced head and neck cancer. We have already experienced 5 cases. In our department, the indications for this treatment are those cases in which we cannot use CDDP because of renal insufficiency and advanced age, or where we cannot use CDDP more 200 mg/m2. Hypopharyngeal cancer was found in 2 of the 5 patients, and 1 case each was mesopharyngeal cancer, laryngeal cancer and cancer of unknown origin. The pathological diagnosis was SCC in all cases and most of them were at a very advanced N stage. In all cases we could not use CDDP because of renal insufficiency and a deteriorating Performance State. A complete response was achieved in 2 cases, partial response in 2 cases and stable disease in only 1. Major side effects were stomatitis and dermatitis, but a feeding tube was required in only 1 case. There was no infusion reaction in this study, but we could not complete the study because of severe side effects: interstitial pneumonia and pseudomembranous conjunctivitis. The rate of successful execution was 60%. There is some possibility that cetuximab with radiotherapy is available as well as chemoradiothrapy. However, because the severe side effects of stomatitis and pharyngitis occurred with furring, there is some possibility that interstitial pneumonia could occur, which is potentially fatal. We therefore have to investigate those side effects and the result of this treatment, before changing from CDDP to cetuximab.
We herein report on a case of a giant tonsillolith that necessitated tonsillectomy. A 35-year-old man had had globus pharyngeus for several years. A thumb-sized nontender hard mass was palpable around the upper pole of his right platine tonsil. CT scan revealed a calcified body measuring 9×19 mm in the right tonsil. Under a diagnosis of tonsillolith, we tried to remove the lith under local anesthesia, but failed. He eventually underwent tonsillectomy under general anesthesia. Histopathological diagnosis was chronic tonsillitis, and component analysis showed more than 98% of the lith was calcium phosphate. The patient's postoperative course was uneventful. He was discharged 8 days after surgery, and has been free from relapse for a postoperative follow-up period of 11 months. Although small tonsilloliths are not rare, some of them may grow into a huge size with only mild symptoms.
We evaluated the activity of the masticatory muscles during oropharyngeal swallowing. Participants included seven volunteers between the ages of 21 and 23 who had no clinical history of difficulty in swallowing. Each participant was instructed to chew and swallow a piece of bread (5-10g), as usual. Surface electromyograms of the masticatory muscles were recorded, including the masseter muscle, temporal muscle, and suprahyoid muscle group. The anterior shift of the thyroid cartilage, which indicates the initiation of the swallowing reflex, was detected using a laser displacement sensor placed in front of the subjects. All data were amplified, logged in a computer, and analyzed off-line. The muscles that open the jaw (the suprahyoid muscle group) and the muscles that close the jaw (the masseter and temporal muscles) contracted alternatively according to rhythmic jaw movements during mastication. At the end of mastication, the jaw-opener muscles and the jaw-closer muscles concomitantly contracted once or several times, leading to the initiation of the swallowing reflex. Co-contraction among the muscles that open and close the jaw has the effect of stiffening the temporomandibular joints. Therefore, during swallowing movements, keeping the mandible in a stable position might be a necessary prerequisite for the transition from the oral to the pharyngeal phase without delay.
Introduction Prognoses of the hypopharyngeal or cervical esophageal carcinomas are in general poor in comparison with other cancers in the head and neck region. However, the prognoses have been gradually improving concomitantly with innovations in the technical skill during surgical procedures or the spread of concurrent chemoradiotherapy (CCRT). The present study indicates validity of treatment to hypopharyngeal or cervical esophageal squamous cell carcinoma in our institution. Materials and methods We investigated the prognoses of 128 cases with hypopharyngeal or cervical esophageal squamous cell carcinoma after treatment during the period from 2006 to 2013. The disease-specific cumulative survival rate was analyzed regarding sex, age, sub-region of the tumors, TNM and stage classification, neo-adjuvant therapy/or not, operation/or CCRT and salvage operation/or not. The disease-specific cumulative survival rate and multivariable analysis were assessed using the Kaplan-Meier method and the Cox proportional hazards model, respectively. Results Survival rates of about 80% over stage III and 60% over stage IV in TNM classification were achieved in our institution. Moreover, there was no significant difference concerning sex, age, sub-region of the tumors, T classification and stage classification and neo-adjuvant therapy/or not. On the other hand, there was a significant difference between the N and M classification. Though there was no significant difference in the prognoses in the choice of operation or CCRT, a better tendency of prognoses was noted in the treatment by CCRT. There was no significant difference in salvage operation/or not. Moreover, it was found that there were many distant metastases in the group of N2b and over in the N classification in spite of the findings for the T classification. Conclusion It was thought that our treatment to hypopharyngeal or cervical esophageal carcinoma is proper strategy according to outcome of treatment by induction chemotherapy and CCRT including CDGP.
Objective: To evaluate the outcome of tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome for patients in whom medical therapy had failed. Methods: Five patients were assessed who had undergone tonsillectomy in our hospital from July 2013 through February 2014. All patients had been on medication before surgery, but the effect was poor. To evaluate surgical treatment of the PFAPA syndrome, we carried out a retrospective study. Result: Prednisolone was administered to all of the patients during acute attacks before tonsillectomy, with a significant antipyretic effect. However, prednisolone administration did not prevent future fever attacks and shortened the interval between episodes. After tonsillectomy, two of the 5 cases were completely free from fever, whereas a fever attack with a longer duration was seen in another 2. Therefore symptoms became less likely to occur following surgery. Despite this finding, fever attacks still continued after surgery in the remaining 1 patient. Conclusions: Tonsillectomy is likely to be a more effective intervention for the long-term resolution of the PFAPA syndrome for patients in whom medical therapy has failed.
The pleomorphic adenoma is the most common tumor of the salivary glands. Although pleomorphic adenomas are classified as a benign tumor, they have the capacity to undergo malignant transformation. The malignant transformation is often associated with a prolonged history of untreated or recurrent pleomorphic adenoma. Distant metastasis of benign pleomorphic adenomas of the salivary glands rarely occurs, and the World Health Organization (WHO) classifies it as a metastasizing pleomorphic adenoma within the category of malignant epithelial tumors of the salivary gland. Metastasizing pleomorphic adenoma can be found after long-term follow-up in the patients with a history of pleomorphic adenoma in the salivary gland. In this study, we report on a 77-year-old female with a metastasizing pleomorphic adenoma of the spine presenting with leg paralysis 13 years after the initial parotidectomy.
Objective: Targeted monoclonal antibodies such as cetuximab are a promising treatment option for patients with cancer, but are associated with a risk of development of infusion reactions (IRs). Cetuximab has a different spectrum of adverse events compared to other antineoplastic drugs due to differences in its mechanisms of action. The aim of this study was to investigate suppression of IRs related to cetuximab using hydrocortisone sodium succinate. Methods: The initial dose of cetuximab was 400 mg/m2. Infusion reactions were assessed based on the NCI-CTCAE criteria (ver. 4.0). Patients were divided into an early group treated with diphenhydramine (Restamin®) and dexamethasone sodium phosphate (Dexart®) and a late group that additionally received hydrocortisone sodium succinate (Solu-cortef®). Rates of infusion reactions in response to the first dose of cetuximab in each group were compared with the Mann-Whitney U test. Results: In the early group, infusion reactions of grades 0 (no event), 1, 2, and≥ 3 developed in 15, 1, 3, and 0 patients, respectively. In the late group, there were 26 infusion reactions of grade 0 and one of grade 3. The incidence of infusion reactions was significantly lower in the late group (p<0.05). Conclusion: Cetuximab can be administered safely with avoidance of infusion reactions with the addition of hydrocortisone sodium succinate to the treatment regimen.
Follicular dendritic cell sarcoma (FDCS) is a rare neoplasm arising from follicular dendritic cells, which are antigen-presenting cells in the lymphoid follicules. An 80-year-old man visited a dental clinic, and an asymptomatic tonsillar tumor was incidentally discovered. A histological examination of the biopsy specimen raised the suspicion of a low or intermediate malignancy. A transoral lateral pharyngotomy was performed for the purpose of total resection of the tumor. The intraoperative frozen pathological diagnosis was squamous cell carcinoma. However the final diagnosis was FDCS based on the immunohistochemical examination of permanent sections. Histologically, a high mitotic count was observed (≧5/10HPF), which is considered as a poor prognostic factor for FDCS. Considering the patient's age and general status, postoperative adjuvant therapy was not applied. He remains disease-free for more than a year and two months after surgery.
It has been reported that antileukotriene therapy improves breathing during sleep for children with mild sleep-disordered breathing (SDB). The expression of the cysteinyl leukotriene1 receptor (CysLT1-R) from dissociated adenoids harvested intraoperatively was investigated through the procedure of immunohistological examination. In 70% of 20 cases, CysLT1-R was expression on vascular endothelial cells and/or interstitial cells. It was revealed in particular that 88.9% of children with house dust mite allergy showed CysLT1-R expression, occurring at a higher rate compared to that of children without house dust mite allergy, of whom 54.5% showed CysLT1-R expression. Therefore, it is considered that antileukotriene therapy could be more effective for children with house dust mite allergy based on the immunohistochemistry findings.
Sleep apnea syndrome has been shown to have a profound impact on the cardiovascular system in children. The serous value of NT-proBNP as a biomarker, ECG, and chest radiography were investigated to assess the cardiac function preoperatively. The subjects included 28 cases undergoing surgery for the disease. In one of the 28, an abnormally-high value of NT-proBNP was identified although abnormalities on ECG and radiography were not found in any case. In echocardiography for the one patient with high NT-proBNP values, two pediatricians mentioned normal or abnormal cardiac function, respectively. In eight of the 28, the serous value of NT-proBNP increased postoperatively. NT-proBNP is reported to be a stable and sensitive biomarker, which may become a useful tool for assessing the cardiac function in the disease. However, we need to consider the upper limitation of the normal values in each age interval, increase of the value due to the non-cardiac acute disease and time for taking a blood sample because of 1-2 hours of resolution time in the body.
Objectives: Adenoid vegetation and palatine tonsil hypertrophy mainly cause sleep disordered-breathing (SDB) in children. Pediatric SDB is highly improved by adenotonsillectomy. We studied the outcome of adenotonsillecomy using the pre and post-surgery polysomnography (PSG). Methods: An adenotonsillectomy was carried out on a total of 39 children with SDB from February 2009 to September 2012. All patients were under 12 years of age at surgery. In accordance with the AASM2007 scoring manual, the obstructive apnea-hypopnea index (OAHI), cummulative percentage at an SpO2 below 90% (CT90%) and Lowest SpO2 (Low-SpO2) were measured, and the outcome of adenotonsillectomy was determined by comparison of the preoperative and postoperative results of PSG. Result : The average value of OAHI was preoperatively 22.5±2.63/h, and postoperatively 1.3±0.17/h. There were 17 cases of “healed”, 21 cases of “improved”, and 1 case of “exacerbated”. Over 90% of children with SDB were healed or improved by adenotonsillectomy. However, adenoid regrowth caused a recurrence of SDB in one case, in which adenoidectomy was performed again one year after adnotonsillectomy. PSG after the second surgery showed “healed”. Conclusions : It was thought that adenotonsillectomy for children with SDB could mostly improve the breathing during sleep with the exclusion of maxillofacial anomalies and obesity. However, adenoid re-growth could occur in some of children with SDB after adenoidectomy. The follow-up of one year after surgery should be considered.
Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN) are rare but life-threatening severe cutaneous adverse reactions (SCARs), which are mainly (65-75%) induced by a variety of drugs. A 57-year-old man visited our ENT facility with a one week history of throat pain and a two day history of skin erythema. Erythema was found over the whole body and stomatitis and laryngitis were observed. The patients was diagnosed as having a severe case of Stevens-Johnson syndrome based on the findings of skin lesion, stomatitis, lung lesion and the pathological findings. A drug-induced lymphocyte stimulation test was negative for all drugs examined. After administration of intravenous predonine (1000mg/day for 3 days) and oral predonine (1.0mg/kg. 50mg/day), the erythema, stomatitis, and lung symptoms were mostly improved. He was discharged from our hospital 15 days after admission without any complications.
A case of a giant submandibular sialolithiasis complicated with a giant tonsillolith is herein. The patient was a 77-year-old female complaining of swelling of the left submandibular region. The CT examination showed large radiopaque masses in the left submandibular area and the left tonsillar area. An operation was performed under general anesthesia. The left submandibular gland and the left tonsillolith were extracted. The salivary stone was divided into five parts, and the total weight was 2.7g. The tonsillolith was 24×20×14mm and weighed 4.5g. The stones were analyzed with infrared absorption spectrometry. Both of them consisted of CaPO4 and CaCO3.
Recently, actinomycosis has become rare owing to the frequent use of antibiotics. Most cases of actinomycosis occur in the head and neck region, but the primary parotid gland actinomycosis is very rare. We experienced a case of parotid actinomycosis that occurred after parotid surgery. A 56-year-old man underwent a superficial partial parotidectomy for a left Warthin tumor. One and a half months later, he complained of a diffuse hard mass in the left parotid gland. It was increasing in size with an unclear border and board-like swelling. The skin surface had a peachblow appearance. After diagnosis of the actinomycosis, treatment consisted of 1.5 months of intravenous penicillin (SBT/ABPC: 12g/day), followed by 9 months of oral penicillin (AMPC 1500mg/day). The patient has shown no sign of recurrence. A possible route of infection could be that actinomyces from the dental surfaces was carried into the parotid gland through Stensen's duct, and the actinomycosis was caused by parotid surgery. Furthermore, it may be promoted by diabetes.