To prevent postoperative facial nerve paralysis in parotid gland surgery, we investigated surgical techniques using two cases of parotid gland tumors. The surgery was performed while observing the surgical field on a magnified screen with a 4K3D video microscope （ORBEYE exoscope） and measuring facial nerve functions with intermittent/continuous nerve monitoring systems （NIM Vital^TM）.
As a result, after exposing the facial nerve branches from the surrounding connective tissue, direct operation on the nerve and indirect external force on the branches by moving the tumor （blood removal operation by gauze compression） caused nerve injury. In addition, operation of the descending branch caused damage not only to this branch, but also to the ascending branch that was not directly treated. As a result, detachment of some branches exerted external force on the branch network of the facial nerve including the main trunk and other branches and led to their nerve paralysis. Therefore, it is conceivable that large tumors, deep lobe tumors, and bleeding-prone tumors, which require surgeons to perform frequent nerve traction and extension operations during surgery, are risk factors for post-operative facial nerve palsy.
The current study was conducted using only two cases; it is necessary to study more cases by the real-time monitoring used in this study and to analyze the surgical technique more accurately. Eventually, it is desirable for surgeons to acquire the skills needed to preserve nerves without costly monitoring.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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The sympathetic-adrenal medulla system （SAM system） reflex to psychological and physical stress affects salivary α-amylase activity （SAA）. This study measured the effects of epipharyngeal abrasive therapy （EAT） on SAA and the SAM system. Among the three groups of the control group, the EAT first group, and the EAT continuation group, there was no significant difference in the psychological stress before the examination, but there was a significant difference in the psychological and physical stress after the examination. Stress significantly promoted the SAM system in the EAT continuation group. Differences in responses to psychological and physical stress were observed in gender comparisons. The mechanism by which EAT affected the SAM system is discussed.

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MALT lymphoma is an extranodal indolent B-cell lymphoma which develops with chronic inflammation or infection. About half of the cases occur in the stomach; occurrence in the oral cavity is rare. We report here a case of MALT lymphoma arising from the minor salivary glands of the palate. A 50-year-old woman was referred to our hospital due to a submucosal mass of 13 mm in diameter in the right soft palate. MRI scan showed a submucosal tumor 13 mm in length，which showed T1-low and T2-high effect. The tumor was surgically removed，and was diagnosed as MALT lymphoma. Based on the results of FDG-PET scan and FNA of other lesions，the patient was judged to be Ann Arbor stage IE and underwent careful follow-up. Since the prognosis of MALT lymphoma has been shown to be good in all stages，careful follow-up can be considered as an option. No recurrence has so far been observed one year after the surgery. Reports of minor salivary gland MALT lymphoma are rare: this is the 14th case reported in Japan. 10 of the 14 cases were associated with Sjögren’s syndrome. The possibility of MALT lymphoma occurring from minor salivary glands should be kept in mind in patients with Sjögren’s syndrome.

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Plasma cell granuloma is a non-neoplastic, reactive lesion with plasma cells. It was formerly known as inflammatory pseudotumor. Plasma cell granuloma most commonly arises in the lung; onset in the whole otolaryngology region is rare. We experienced a case of nasopharyngeal plasma cell granuloma; we report the clinical and pathological features, with a review of the literature. The case was a 68-year-old female. An examination by FDG-PET revealed an accumulation in the nasopharynx, so she was referred to our department for a close inspection and medical treatment. A nasopharyngeal mass was detected and a biopsy was performed, but there were no malignant findings, so the patient was followed up for several years. Five years later, nasal congestion appeared and an increase in the nasopharyngeal mass was observed. The surgical policy was to improve and diagnose the nasal congestion. Histopathological examination revealed plasma cell granuloma. As in the present case, FDG-PET may reveal accumulation in the head and neck region, but if there are no malignant findings in the biopsy histology, follow-up is often terminated. If there is no definitive diagnosis, regular follow-up may be necessary even if there are no malignant findings.
We described our experience of a case of nasopharyngeal plasma cell granuloma. The case was a 68-year-old female. The nasopharyngeal mass was detected and performed a biopsy. There were no malignant findings of this mass, thus, a follow-up of this patient was over. Five years later, the nasopharyngeal mass increased and, this patient experienced nasal congestion. We resected nasopharyngeal mass and the mass was diagnosed with plasma cell granuloma.
Plasma cell granuloma is a non-neoplastic, reactive lesion with plasma cell. It was formerly known as inflammatory pseudotumor. A follow-up of the benign tumor may be necessary, if there is no definitive diagnosis.

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Infectious pseudoaneurysm is a relatively rare disease. In this report, we describe a case of fatal bleeding due to an infected pseudoaneurysm secondary to peritonsillar abscess. The patient, a man in his 70s, was admitted to the hospital with a diagnosis of peritonsillar abscess after visiting his previous doctor with complaints of pharyngeal pain and swelling of the pharynx. After the start of puncture drainage and antibacterial treatment, his progress was good and he was discharged from the hospital, but he was admitted to the hospital again due to hematemesis immediately afterwards. The next day, his hematemesis continued and it was difficult to stop the bleeding, so he was rushed to our hospital. Angiography showed contrast leakage from a pseudoaneurysm formed in the squamous branch of the facial artery, and arterial embolization was performed. Postoperatively, the patient progressed without any new bleeding and was discharged. The peritonsillar abscess was thought to have formed a pseudoaneurysm due to the spread of inflammation, resulting in fatal bleeding. When the formation of a pseudoaneurysm is suspected, it is essential to promptly pursue the cause, and to take appropriate evaluation and prompt action.

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OK-432 （Picibanil^Ⓡ） is a penicillin-inactivated, low-toxicity strain of group A Streptococcus. It is widely used in Japan as an immunotherapeutic agent for malignant tumors. Sclerotherapy with OK-432 is recommended as the optimal treatment for ranula because it is minimally invasive and safe. This study reports four patients with shrunken ranula treated with OK-432 local injection therapy. In three cases, the content of the ranula was aspirated to the maximum extent possible, and then a volume of the OK-432 solution equal to the aspirated volume was injected. In one case, the OK-432 solution was injected at a high concentration without aspirating the contents of the ranula. All cases were followed up using ultrasonography. After 6 weeks, all cases showed shrinkage of the ranula. In one case, a re-enlargement of the ranula was observed 5 months after post-injection, but it resolved spontaneously after 4 months. Eventually, disappearance of the ranula was noted in all cases. Adverse effects, including fever lasting for 2-3 days （3/4 cases） and local swelling for 3-5 days （2/4 cases）, were identified. Sclerotherapy with OK-432 appears to be an effective and safe treatment and may be the first choice for ranula before considering surgery.

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The occurrence of malignant lymphoma as a secondary duplication of head and neck cancer is rare. The patient was a 67-year-old man with superficial hypopharyngeal carcinoma who underwent endoscopic laryngo-pharyngeal surgery three times. The pathological diagnosis was squamous cell carcinoma, pT2, pT2, and pT1, respectively. At 11 months after the first endoscopic laryngo-pharyngeal surgery, cervical ultrasonography showed lymphadenopathy with loss of lymphatic hilum on the left Level IB, and FDG/PET-CT showed hyper-accumulation of FDG. 18 months later, lymphadenectomy was performed and the diagnosis of follicular lymphoma was confirmed. When occult cervical lymph node metastasis is located at an atypical site, rare conditions such as complications of malignant lymphoma should be considered. Lymph node biopsy may be useful if cytology does not provide a definitive diagnosis.

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A pyriform sinus fistula is a congenital fistula tract derived from the third, fourth, or fifth pharyngeal sac, which causes recurrent cervical infections due to bacterial invasion. Treatment includes medical therapy such as antimicrobials during the acute phase of inflammation, and, if necessary, incisional drainage. Fistulotomy through an external cervical incision is generally performed as a curative treatment. However, in recent years, there are reports of transoral cauterization of fistulas. In this study, we report three cases of pyriform sinus fistulas treated with transoral fistula cautery. Case 1 was an 18-year-old boy who presented for the treatment of recurrent cervical subcutaneous abscesses. In this case, transoral electrical cauterization was followed by chemical cauterization with 40% trichloroacetic acid. Case 2 was a 7-year-old girl who developed a cervical infection due to trauma. After medical treatment, a pyriform sinus fistula was noted, and transoral electrical cauterization and fibrin glue application were performed. Case 3 was a 46-year-old woman who presented for examination and treatment of recurrent suppurative thyroiditis. She underwent transoral electrical ablation followed by fibrin glue application. Recurrence of cervical infection was not observed in any of the cases. Transoral fistula cauterization is less invasive than external cervical incision, more cosmetically pleasing, and requires less operative time and hospitalization. There are no reports of a higher recurrence rate of cervical infections than with external cervical incision. Therefore, we recommend that transoral fistula cauterization be performed before external cervical incision.

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Angiosarcoma is a rare but highly aggressive malignant tumor that accounts for 2-3% of all soft tissue sarcomas. We experienced two cases of head and neck angiosarcoma. The first was a case of angiosarcoma originally arising in the right parotid gland. Despite surgical treatment for the tumor, it recurred and progressed in a few months. The patient died of lung metastases followed by the pneumothorax. The second case visited our institution with primary angiosarcoma of the lower gingiva. Since this tumor also showed remarkably rapid growth, semi-urgent surgical treatment was chosen without reconstructive surgery followed by adjuvant chemotherapy using paclitaxel. The patient remains alive with no recurrence for more than three years. As its clinical features are aggressive, prompt diagnosis and treatment are essential.

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A 45-year-old woman noticed a painless mass in the left parotid region 3 months before she visited our hospital. A 2-cm mass was found in the superficial lobe of the left parotid gland. Magnetic resonance imaging and fine needle aspiration cytology suggested benign parotid tumors such as pleomorphic adenoma or Warthin tumor. The patient underwent superficial parotidectomy. Histologically, the peripheral part of the mass contained an abundant fat component. In the central part, tubular and cribriform epithelial hyperplasia with apocrine-like metaplasia were focally seen in the fibrotic background, and eosinophilic granules could be observed in acinar cells. Therefore, we diagnosed this case as sclerosing polycystic adenosis （SPA）. The patient has been followed without recurrence for one year. SPA is a rare, benign salivary disease commonly arising in the parotid gland. Careful follow-up is required because some cases of recurrence or malignant transformation have been reported.

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Full-scale three-dimensional models of organs are widely used as a surgical support tool for the skull, temporal bone, mandibular bone, etc. in the fields of otolaryngology and head and neck surgery.
We experienced a patient with submandibular cancer that invaded the facial skin and mandible extensively and performed reconstruction with a mandibular titanium plate and free rectus abdominis flap. Since the tumor was raised on the surface of the mandible and infiltrated the vicinity of the coronoid process, resulting in a fracture, it was possible to perform rigid reconstruction that maintained left-right contrast by creating a mirror-image model of the healthy mandible. The details of the 3D model created before the operation and the course of treatment are reported with a review of the literature.

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[in Japanese]

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Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis （PFAPA） syndrome is an autoinflammatory disease and is generally seen in children under 5 years of age. Because the etiology and pathogenesis of PFAPA syndrome are unknown, the syndrome is often misdiagnosed as recurrent tonsillitis. Medication is normally chosen for the first treatment, but tonsillectomy is considered when the medication is ineffective. Herein, we report five cases of PFAPA syndrome who underwent tonsillectomy in our department. The age of onset ranged from 0 to 5 years （median 3 years）, and the age at tonsillectomy ranged from 2 to 7 years （median 5 years）. Symptoms included periodic fever in 5 cases, aphthous stomatitis in 1 case, cervical lymphadenitis in 2 cases, and pharyngitis in 5 cases. After tonsillectomy, the periodic fever disappeared in four cases, and the fever onset became less frequent in the remaining case. Therefore, tonsillectomy was effective in the treatment of PFAPA syndrome. When patients are introduced by a pediatrician who suggests that tonsillectomy is indicated because of failure of the initial treatment, we should recommend the operation for the patients.

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Minor salivary glands are widely distributed on the lips, tongue, buccal mucosa, hard palate, etc. It has been reported that minor salivary gland tumors account for about 10-15％ of all salivary gland tumors, and that about 50％ of them are malignant, which is a higher proportion than for major salivary gland tumors.
Cribriform adenocarcinoma of minor salivary glands （CASG） is a very rare type of salivary gland carcinoma. Although CASG is considered to be a variant of polymorphous adenocarcinoma （PAC） under the World Health Organization classification, it is controversial whether CASG and PAC should be considered within the same classification because of the differences between their histopathological and genetic features.
A 63-year-old man visited us complaining of swelling of the left mandible for 2-3 months, and a hard tumor was palpable not only on the left side of the neck but also in the left tongue base. MRI showed a lobular and capsulated neoplastic lesion about 50 mm in size on the left side of the base of the tongue, and some left cervical lymph nodes were swollen. Biopsy of the base of the tongue tumor revealed only normal mucosa, but fine needle aspiration cytology for cervical tumors found suspected adenocarcinoma. We performed surgical excision of the tumors. From the clinical characteristics, findings typical of CASG were observed, but the histopathological characteristics of PAC and CASG were mixed. Genetic analysis was not performed for this patient. There have been no signs of recurrence during observation for three years and one month after the operation.
We have previously experienced cases in which the characteristics of PAC and CASG were mixed. To determine whether PAC and CASG should be treated as different diseases, it is important to carry out further studies in the future.

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There are about 24,000 people living on 11 inhabited islands in the Tokyo metropolitan area. Although there are no villages without a doctor on these islands and there are medical institutions with resident doctors, in some cases medical facilities and systems are not sufficient, and referrals to and cooperation with local medical institutions are necessary. In this report, we describe a case of multiple endocrine neoplasia type 1 （MEN1）, which was found by a physician on an island and diagnosed as MEN1. Because MEN1 causes neoplastic lesions in multiple endocrine organs, it is necessary to treat MEN1 patients in a cross-sectoral manner, and so it is desirable to establish a good system for cooperation between medical institutions on the islands and those on the mainland.

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