It has been reported that free radicals may induce gastric ulcer and dermal ulcer, but the relationship between oral ulcers and free radicals remains ambiguous . The superoxide (O2-2) and hydroxyl radicals (OH·) produced from oxygen and the radio-hydrolysis of water are responsible for lipid membrane injury. In this study each rat received two doses of irradition for a total dose of 40 Gy, and oral ulcers appeared on the eighth day. Superoxide dismutase (SOD) was measured quantitatively by the cytochrome C method, and the distribution of SOD was demonstrated immunohistochemically. OH· was also measured by ESR. The intracellular distribution and the intracellular quantity of SOD was not changed by irradiation. OH·trapping by ESR increased with time. In hematoxylin and eosin stains neutrophils were seen in contact with endothelial cells of postcapillary vessels. Capillary casts were convoluted and sinusoidal. These results suggest that OH· produced by neutrophils in contact with endothelial cells might damage capillaries and lead to ulceration.
HLA antigens were determined in 27 patients with recurrent oral and pharyngeal ulcers: 3 with Behcet's disease, one with pemphigus vulgaris, 6 with intractable ulceration of unknown cause and 17 with aphthous stomatitis. The controls were 81 healthy subjects. The frequencies of HLA-DRw6, -DR7, -DRw8 and -DRw52 were significantly greater in the patients than in the healthy controls. In contrast, the frequency of HLA-DRw9 was significantly lower. Since HLA-DRw8 and -DRw52 are associated with Behcet's disease, some of these patients may develop Behcet's disease.
During last 8 years, 5 patients (3 males and 2 females, aged 20-53 years) were diagnosed and treated for recurrent ulcers of the oral cavity and pharynx in this hospital. All of the patients complained of sore throat, dysphagia and moderate fever . The laboratory examinations showed positive CRP 4/5, increased ESR 4/5, increased WBC count 1/5, increased serum IgA 3/5 and IgG IgM 2/5. In 4 patients Candida albicans was isolated in specimens from the oral cavity. In all 5 patients the pathological diagnosis was nonspecific inflammation with ulceration. The patients with acute phase ulcer were treated with steroids followed by periodic Broncasma Berna injections to prevent recurrence of the ulcer. The effectiveness of steroid was different in each patient. In one case pharyngeal ulcers disappeared after only 1 week of treatment with a small amount of steroid, but in another case steroid had little effect. In 2 of 3 patients who received Broncasma Berna injections for up to 28 months the recurrence of ulcers disappeared. There were some differences in the laboratory data and the effectiveness of steroid and Broncasma Berna therapy in the 5 patients, suggesting that the ulcers in this disease have various causes.
We used the low powered LASER to treat two patients with inveterate oral and pharyngeal ulcers. We irradiated the ulcers 14 times and achieved succcess in both patients. We conclude that low powered LASER is useful in the treatment of inveterate oral and pharyngeal ulcers.
There are many diseases, including aphtha, herpes, traumatic ulcers, Behget's disease, various skin diseases, sexually transmitted diseases (STD) and malignant tumors which are accompanied by persistent ulcers in the oral cavity. Many laboratory examinations are used in the diagnosis, but the most important aids are the clinical findings and the results of bacteriological examinations along with repeated histological examinations of biopsy materials from the oral cavity. It is also important to bear in mind the possibility of STDs in establishing the diagnosis.
The cause of Behcet's disease is still unknown. In this paper, we describe the features of Behcet's disease as reported by the Japan Ministry of Health and Welfare in 1987. Behcet's disease is characterized by oral and genital ulcers and ocular inflammation. At least two of these main symptoms are required to establish the diagnosis. Behcet's disease is further classified as having mucocutaneous, arthritic, digestive, vascular and neurologic abnormalities. Behcet's disease must be differentiated from benign mucous membrane pemphigus, pemphigoid and erythema multiforme. The ulcers in recurrent aphthous stomatitis are quite similar in appearance. These diseases can be ruled out with pathological and immunological techniques.
Carcinoma in pleomorphic adenoma (malignant mixed tumors) is believed to originate from benign pleomorphic adenoma. A knowledge of the pathological and etiological features of carcinoma in pleomorphic adenoma is very important in the prevention of malignant change. We examined carcinoma in plemorphic adenomas (5 males and 1 female) of the parotid gland treated in Okayama University Medical School Department of Otolaryngology from 1976 to 1992. These tumors accounted for 26.1% (6/23) of all parotid carcinomas. The ratio of malignant mixed tumors to benign pleomorphic adenomas was 6/48 (11.1%). The mean age of the 6 patients was 57.8 and the mean duration before surgical removal was 21.7 years. Both values show a statistically significant difference from those of patients with benign pleomorphic adenomas (p<0.05). The malignancy of each case with carcinoma in pleomorphic adenomas was histologically diagnosed as adenocarcinoma in 6 cases. In 60% (3/5) of the malignant mixed tumors, overexpression of c-erb B-2 was detected by immunohistochemical staining, but there was no significant amplification of ras or p53. Moreover, 67% (2/3) of the c-erbB-2-positive malignant mixed tumors had neck metastasis. It is speculated that the overexpression of c-erbB-2 may play a role in the malignant change of plemorphic adenoma or in the progression of malignant mixed tumor.
Microscopic and immunohistochemical studies were carried out to clarify the relationship between pseudocapsules and cell dissemination in pleomorphic adenomas. Eighteen primary treated tumors (primary tumors) and six recurrent tumors were classified into three types depending on their cellularity: typical type (25-75% cells), cellular type (>75% cells) and myxoid type (<25% cells). The thickness of the tumor-capsules in tissue sections were determined with an image-analyzer. The biological activities of tumor cells were demonstrated immunohistochemically with proliferating cell nuclear antigen (PCNA) antibody. T cells and B cells around the capsules were detected by their reactions with anti -T (UCHL-1) and ant-B (DAKO-L-26) antibodies, respectively. Myxoid type tumor was the most common recurrent tumor, although the original predominant type was cellular followed by typical and myxoid types . Of the primary tumors, the myxoid type had the thinnest capsule . The degree of lymphocyte infiltration around the tumor capsule, but not the T/B ratio was related to the thickness of the capsule. Scattered PCNA-positive cells were present in both primary and recurrent tumors. The above results indicate that the tumor type and the thickness of the capsule play more important roles in cell dissemination during surgical procedures than do the biological activities of tumor cells in pleomorphic adenomas.
The fundamental goals of parotid plemorphic adenoma surgery are: 1) prevention of recurrence, 2) preservation of the facial nerve, 3) prevention of postoperative Frey's syndrome, 4) preservation of salivary gland function and 5) shortening of operation time. A retrospective study of 196 patients with benign pleomorphic adenoma who underwent partial parotidectomy showed no recurrence and an 18% incidence of facial nerve weakness and Frey's syndrome. In comparison with the reported results of enucleation, and lateral or superficial parotidectomy, partial parotidectomy with preservation of the facial nerve seems to satisfy the 5 goals mentioned and is preferable for benign parotid tumors.
The development of the pharynx was studied in human embryos and fetuses . Embryos and fetuses from 4.5mm crowm-rump length (CRL) to 40mm CRL were processed for microscopy. Their pharyngeal regions were examined mainly in sagittal sections . Fetuses from 32mm CRL to 250mm CRL were fixed and cut sagittally through the midline and their pharyngeal regions were examined macroscopically. Fetuses with severe malformations of the central nervous system (CNS) were also cut sagittally through the midline and examined. We found that the early formation of the pharyngeal roof is influenced by the separation of the notochord and the formation of the skull base. In later stages of development, growth of the mandibular portion and extension of the vertebral column contribute to the formation of the pharyngeal lumen. Fetuses with severe malformation of the CNS such as hydrocephalus, anencephalus and craniorachischisis show significant deformity of the pharynx. Malformation of the CNS induces malformation of the skull base and cervical vertebral column, which influences the formation of the pharynx.
Since 1755, when choanal atresia was first described by Roederer, more than 300 papers have appeared in the literature describing various aspects of choanal atresia. Three patients with congenital unilateral choanal atresia (2 males and a female) were treated surgically in our deparutment. Today's preferred methods of repair are transnasal and transpalatal. Each method has its advantages, disadvantages, proponents, and opponents. A transpalatine aproach and the use of carbon dioxide or Nd: YAG laser seemed better for recurrent cases. A tube stent should be placed for at least 6 weeks postoperatively. Long-term follow up is necessary.
The incidence of congenital choanal atresia is 1 per 8000 births. From 1980 to 1992, eight patients with choanal atresia were treated in our facility. The female to male ratio was 5: 3, which is consistent with the widely-reported 2: 1 sex ratio . One patient, a girl, had unilateral osseous obstruction with membrane closure of the opposite nare while the other seven had bilateral osseous obstruction. Seven of the eight had other congenital anomalies, CHARGE association (2), Apert syndrome (1), meningocel and banded fingers (1), omphalocele (1), subdural hematoma (1) and nasal fistula (1). Of the seven patients who underwent endonasal surgical repair, three (40%) experienced reclosure. A second operation was successful in two and a third operation was successful in one. The remaining one patient, whose obstruction was of the bilateral osseous type, was successfully operated on via a transpalatal approach. Surgical correction is particularly difficult in those with a craniofacial abnormality, e.g. Apert syndrome and maxillary hypoplasia. We treated four patients, three boys and one girl, with congenital nasopharyngeal stenosis from 1980 to 1992. Surgical correction was successful in three of them . To date, the other child has had persistent nasopharyngeal atresia associated with sinusitis and secretory otitis media. To our knowledge, these are the first cases of congenital nasopharyngeal stenosis to be reported in the literature.
Seventeen Patients with craniofacial synostosis (CFS) were treated in the Department of Plastic and Reconstructive Surgery at Osaka Medical College during the past 10 years. Six patients were evaluated thoroughly in the Department of Otolaryngology with polysomnography (PSG), cephalometric X-ray and nasopharyngoscopy during sleep. PSG of four patients showed obstructive sleep apnea syndromes (OSAS). Heavy snoring without apnea and paradoxical respiration were noted in the other two patients. Thus, all of them had sleep respiratory disorders (SRD). It is assumed that the incidence of SRD in CFS is high. Cephalometric analysis showed maxillo-mandibular dysplasia in all of them. It is assumed that main cause of SRD in CFS is stenosis of the upper airway tract caused by maxillo-mandibular dysplasia. Nasopharyngoscopy during sleep was performed in two patients with OSAS secondary to CFS. One patient with adeno-tonsillar hypertrophy had nasopharyngeal obstruction and another whose posterior airway space (PAS) on cephalometric X-ray was 3mm (normal range: 11mm) had an obstruction at the tongue base. The former was treated with a Le Fort I osteotomy, horizontal mandibular osteotomy and uvulopalatopharyngoplasty, the latter with a Le Fort III osteotomy and adenotomy. Patients were free of obstructions after surgery.
The author describes the indications and the optional age for operation for complex craniosynostosis in such conditions as Apert's syndrome and Crouzn's disease. Routine operations of choice are described including the author's modification of fronto-facial advancement for adult candidates, i.e. LeFort 4 minus glabellar osteotomy. The sphenoid bone is thought to be the key to the development of the features of complex craniosynotosis, and its wide exision is important along with simultaneous reconstruction of the infratemporal area and lateral wall of the orbit. The sleep apnea syndrome in craniosynostosis was evaluated in relation to the width of the upper and middle pharyngeal space and to the dimensions of the maxilla and mandible measured on cephalograms. The latter was found to have a close relationship with sleep apnea syndrome. For complex craniosynostosis with sleep apnea the mandible as well as the maxilla should be treated; that is, horizontal mandibular osteotomy to widen the floor of the mouth should be included. A 3 D solid model for preoperative evaluation and operative planning or simulated surgery was found to be very useful.
Swallowing dysfunction and aspiration are the most common cause of recurrent pneumonia that could be fatal for children. The exact cause is still unknown. In this study, we evaluated the swallowing function in 100 children by fluoroscopy and followed the course of 45 children after aspiration. The results of all the examinations were recorded on videotape or a digital imaging system. Results. In all of the 45 patients with clinical signs of aspiration, the diagnosis was confirmed by examinations. All of the 7 mentally retarded patients showed cricopharyngeal dysfunction. Of the 27 patients without any neurologic disorder, 18 had cricopharyngeal dysfunction. There were 3 aspirations in children without cricopharyngeal dysfunction or nasopharyngeal reflux. These 3 had poor elevation of the larynx, which is essential to prevent aspiration. Of the 12 near miss sudden infant death syndrome patients, 10 had aspiration without any specific findings. All 27 patients without any neurologic disorder had recovered well. Of the 18 patients with neurologic disorders, 7 had prolonged symptoms for 1 year or longer. Conclusions. There are two types of aspiration. One is caused not only by pharyngeal musle but also by lingual muscle. It is not associated with any neurologic disorders, and it is transient. The other type of aspiration is caused by cricopharyngeal muscle dysfunction, and most of these patients have neurological diseases and prolonged symptoms.
Tornwaldt's disease, which was first described by Tornwaldt as one of the causes of epipharyngitis, is inflammation or abscess of the embryonic remnant cyst of the pharyngeal bursa appearing at the posterior median wall of the epipharynx. Although many cases are asymptomatic, symptoms are often caused by nasal tamponade, trauma, adenotomy, or other mechanical stimuli. Only a few cases have been reported from 1929 till 1992 in Japan. In about the 10th week of embryonic development the pouch, which is made by adhesion of the pharyngeal ectoderm to the notochord at the most cranial end of the notochord, is closed at the orifice (cystic type), or crusts adhere to the orifice without closing (crust type). The symptoms are those of upper respiratory tract infection with obstinate occipital pain, purulent choanal discharge, nasal obstruction, halitosis, feeling of ear fullness, clearing of the throat, etc. Posterior rhinoscopy, simple lateral view X-ray tomography, nasopharyngeal fiberscopy, CT scan and MRI are useful in showing adhesion to the cervical vertebrae. While complete extirpation via a transpalatal approach is desirable, incision or excision of the cyst can also be performed.
We have treated four patients with odontogenic phlegmon of the oral floor. Two of the four had diabetes mellitus, and one had suffered a mandibular fracture during tooth extraction. The four patients did not respond to antibiotic therapy, but symptoms were significantly relieved by incision and drainage.
We treated 13 patients with oropharyngeal syhilis from 1983 to 1991 . Most of the lesions were mucous patches, but there were also some ulcers and flares . We biopsied the lesions and observed them under light and electron microscopes. Neutrophils and plasma cells were the main components of the lesions; there were no eosinophils or mast cells. We therefore did not consider that these lesions were due to an allergic reaction. Marked invasion of plasma cells and lymphocytes was observed around blood vessels, and many neutrophils were seen in the epithelial cell layer . There cells showed signs of chronic inflammation. The fact that neutrophils tended to decrease after the start of antisyphilitic therapy suggests that they play an important role in stagell of this disease.
The incidence of tuberculosis has decreased markedly in Japan thanks to the availability of antituberculous chemotherapy. Therefore, oral lesions due to tuberculosis are rarely seen nowadays. We describe here a 23 year-old-woman who presented with a persistent sore throat which had been treated with antibiotics and local remedies for three weeks before the diagnosis was made of tuberculosis of the pharynx associated with active pulmonary tuberculosis. On admisson, examination of the pharynx revealed an ulcerating lesion of the soft palate on the left side. Biopsies of this lesion revealed a chronic granuloma containing plasma cells, lymphocytes, and giant multinucleated Langerhans type cells, consistent with a diagnosis of tuberculosis, fungus or other specific inflammation. Staining with Ziehl-Neelsen, Grocott and PAS methods revealed an abundance of alcohol and acid-fast bacilli in direct smears of the sputum. Cultures proved that the organism was Mycobacterium tuberculosis, sensitive to streptomcin, PAS and isoniazid. She was treated with intramuscular streptomycin 1.0g, oral REP 450 mg, and isoniazid 300 mg daily for 6 months. She also received pyridoxal phosphate 60 mg daily. The pharynx and soft palate were healed 3 months after the start of treatment, and she was symptom free. This case is described in detail and compared with previous cases reported in Japan. It is a reminder that a once very common disease is still present.
Sixty two patients suspected of having styloid process syndrome were examined radiographically in our department from January, 1989 to April, 1992. We usually examine the styloid process with bilateral skull radiographs with the X-ray source in contact with the skull. The calculated mean length of the styloid process, which ranged from 0 to 80mm, was 24.3 ± 7.9mm (mean ± S.D.). There was no significant correlation between age and length of the styloid process. Styloid process syndrome was diagnosed in six patients, and surgery was performed with excision of the styloid process via an intraoral approach. Their symptoms were relieved or decreased postoperatively. Orthopantomography is more useful than lateral skull radiography for measurement of the styloid process, but antero-posterior tomography or CT scan is more valuable if medial or lateral angulation of the styloid process or its relation to the surrounding organs is to be examined in detail.
A 52-year-old female felt pain in her throat immediately after swallowing Chinese noodles. She complained subsequently of abnormal sensation in her throat and of swelling and tenderness of the upper right side of her neck. When she visited our outpatient clinic, Horner's sign was noted. Neck X-rays and CT scans showed a foreign body. This was removed surgically. It was a piece of wire which looked like part of a metal basket. It had probally passed into the neck through the side wall of the mesopharynx when she swallowed the noodles.
The upper respiratory tracts of 61 subjects, including normal controls and persons with acute upper respiratory tract infections, were examined bacteriologically. The β-lactamase production capacity of the isolated strains was assessed. S. sanguis and S. salivarius were often found in the palatine tonsil, S . aureus in the epipharynx and CNS in the middle meatus of the nose. No significant difference in β-lactamase production capacity could be found between the control group and the inflammation group.S. aureus and CNS were isolated frequently as suspected pathogens or so-called “indigenous bacteria”, and the rates of β-lactamase production of these strains were high. The β-lactamase produced by these indigenous strains would thus appear to be a factor of “indirect pathogenesis” in upper respiratory tract infections.
A histopathological study was performed on 31 nonspecific chronic ulcers which persisted in the oral cavity for more than 3 weeks . We examined the epithelial margins and bases of the ulcers in detail. In this article we described especially the superficial layer of the ulcer base. There were many different features, both macroscopic and microscopic. We classified the 31 ulcers into 5 groups; Group A: Base consisting of three distinct layers: exudate, fibrin deposits, and granulation tissue (5 cases; 16%). Group B: Granulation tissue directly exposed to the oral cavity without any other layers but with fibrotic changes on the surface (11 cases; 35%). Group C: Granulation tissue covered with a thick fibropurulent layer with intense infiltration of inflammatory cells (5 cases; 16%). Group D: Granulation tissue covered with two layers: one of necrosis and one of fibrin deposits (4 cases; 12%). Group E: Granulation tissue covered with a thick layer of necrosis but no fibrin deposits (6 cases; 19%).
Post-operative speech and swallowing were examined in 46 patients with tongue, oral floor or oropharyngeal cancer. Speech function after surgery for tongue or oral floor cancer depended on the extent of tongue resection. Speech function after hemiglossectomy was best if reconstruction was performed with a free rectus abdominis myocutaneous flap, and worst in those in whom a pectoralis major myocutaneous flap was used. Although the degree of speech intelligibility of patients with oropharyngeal cancer was superior to that of patients with tongue or oral floor cancer, articulation was not good because of rhinolalia aperta after reconstruction of the soft palate. Mandibular transection or resection during surgery was considered to be related to post-operative speech and swallowing functions. The age of the patient was only slightly related to post-operative function.
One hundred patients with tongue cancer treated at Mie University Hospital from 1975 to 1991 are reviewed, with special attention to prognosis and recurrence . Survival rates were analyzed by the Kaplan-Meier method. The 5-year survival rate was 85 .52%, 73.93%, 31.75% and 45.55%, respectively, for those with stage I, II, III and IV cancers . Thirty nine of these patients were treated with intra-arteria 1 chemotherapy. The survival rate of the T3 group was high and improved the over-all survival rate. Combination therapy with systemic chemotherapy is necessary to improve the prognosis of tongue cancer patients
During the past 15 years, 170 patients with parotid tumors were treated in the Department of Otorhinolaryngology of Mie University Hospital: 128 benign tumors and 42 malignant tumors. Pleomorphic adenomas were the most common of all the tumors, 70.3% of benign tumors. Mucoepidermoid carcinomas were common malignant tumors. Spontaneous pain, tenderness, and facial palsy were frequently observed in patients with malignant tumors. Frey's syndrome occurred in 11.3% of the patients with benign tumors and in 50.0% of those with malignant tumors after operation. The five-year cumulative survival rate was 87.5% for mucoepidermoid carcinoma (low grade malignancy), 80.0% for adenoid cystic carcinoma, 25.0% for mucoepidermoid carcinoma (high grade malignancy), and 0% for carcinoma in pleomorphic adenoma and for squamous cell carcinoma.
We examined the diagnostic significance of serum amylase isozymes in patients with sialadenitis etc. To establish a normal value of serum amylase isozymes, we first examined the sera from normal adults. Amylase isozyme patterns of sera, which were obtained from the patients 24 hours after infusion of contrast media into the parotid gland for sialoglaphic examination, were characterized as marked elevation of S1, slight elevation of S2 and marked reduction of Plevel, when compared to the normal pattern. Additionally S3 wave was found in the patients, which did not be found in the normal individuals, although the value of Slevel was not different from the normal. The similar patterns were observed in patients with parotitis. The serum levels of amylase and its isozymes were measured for 17 days after sialoglaphy of the parotid gland in a normal adult. Then S1 level fell more slowly and returned more slowly to the normal value than did the serum amylase level, and similar patterns were also observed in patients with parotitis. Amylase isozyme patterns, therefor, could be useful for diagnosis of the parotitis even after serum amylase levels became normal value. We examined serum levels of amylase and its isozymes in patients with sialolithiasis of the submandibular gland and in normal adults after sialoglaphy of the submandibular gland, but there were no significant changes. Next we examined serum amylase isozymes in patients with dry mouth. Most of the patients with normal sialographic findings or with normal gum tests showed normal patterns, but some of them showed a definite change: elevated S1 levels or the appearance of S3 waves. Elevated P levels and reduced S and S1 levels were observed in patients with abnormal sialographic findings or with reduced gum test values.
A 59-year-old man was transferred to our clinic because of submandibular swelling. An isodense mass and some lymphnodes were found in the submandibular region in the neck on CT scan. The mass was faintly radioactive with Ga-scintigraphy. We decided to remove the mass surgical by. Additional treatment was not carried out, because of side effects. Histologically the surgical specimen showed proliferation of lymphofollicular and granulation tissue with fibrosis. These findings are those of Kimura's disease. The majority of authors have suggested that if this disease is treated only surgical by there is a high incidence of recurrence. The observation period since surgery has been only 9 months, and there have been no signs of recurrence. We feel that periodic examinations are needed for a long time.
The parapharyngeal space is a complicated structure anatomically, including important tissues such as blood vessels and nerves. Imaging diagnosis is essential for the diagnosis of tumors in this site. With imaging techniques such as CT and MRI, it was possible to estimate the location of the tumors in relation to the parotid gland, and by the direction of compression of the carotid arteries, styloid process and parapharyngeal fatty tissue (PFT) caused by the presence of the tumor. In tumors originating in the deep lobe of the parotid gland, the internal carotid artery (ICA) was shifted posteriorly, and the PFT was compressed anteromedially. In tumors originating in the small salivary glands, there was a distinctly visible boundary between the tumor and the parotid gland, and the ICA was shifted posterolaterally. In neurilemmomas originating in the cervical sympathetic nerve, the ICA was stifted anteriorly and slightly laterally, and the PFT was displaced anteriorly, making it possible to differentiation it from neurilemmomas of vagal origin. Enhanced CT, MRI and DSA were useful in determining the relationship of the tumor to the carotid arteries.
In acute tonsillitis, the palatine tonsils are swollen and a whitish debris can be seen in its crypts. In these cases, it seems that macrophages and lymphocytes are activated, and an immune reaction has been elicited to dispose of the bacterial antigen and produce specific antibodies. Previously, Miyakogawa et al. demonstrated differences in immunoglobulin localization between acute and chronic tonsillitis by immunofluorescent staining, but B-and T-lymphocyte population as well as theri subpopulations have been identified with the use of several monoclonal antibodies. We attempted to stain tonsillar tissues obtained from patients with tonsillits, using immonohishologic staining techniques and compared the specimens from patients with chronic tonsillitis. We found that, in acute tonsillitis, T-lymphocytes infiltrated the follicular area, especially the mantle zone, more than they did in chronic tonsillitis. Moreover, some activation markers, such as Ki-67, CD25. and CD71, were stained more distinchly and, in follicular areas, the staining pattern of B-lymphocyte markers was different from that seen in chronic tonsillitis. These findings show that the location and differentiation of tonsilar lymphocytes is very different in acute inflammation.
The total apnea number (TAN) and apnea index (AI) of 20 patients with sleep apnea syndrome (SAS) obtained by apnomonitor were evaluated and compared with the data obtained by polysomnography (PSG) performed simultaneously on the same patients. The patients were 17 males and 3 females, aged 7 to 59 years. The Body Mass Index (BMI) of the patients ranged from 14.3-34.4kg/m2 (mean±SD, 24.8±4.98kg/m2). AI values obtained by apnomonitor were higher than those obtained by PSG in 12 patients (60%), lower in 3 patients (15%) and nearly equal in 5 patients (25%). TAN values obtained by apnomonitor were higher than those obtained by PSG in 15 patients (75%), lower in 2 patients (10%) and nearly equal in 3 patients (15%). In 2 patients, AI and TAN values obtained by the two kinds of monitoring were almost equal. The data suggest that the sensitivity of apnomonitors is somewhat less accurate than that of PSG. Consequently, we recommend that apnomonitors be used with pulse oximeters for the screening of SAS patients.
Movement disorders of the vocal folds of seven patients with multiple system atrophy (MSA) were examined with a fiberoptic laryngoscope, and limitation of vocal fold abduction was found in six patients. Polysomnographic studies revealed only one patient with sleep apnea syndrome in the seven MSA patients. Sleep nasendoscopy after an intravenous injection of diazepam revealed that the cause of loud snoring was a narrow glottis. In one patient limited vocal fold abduction was observed only during sleep. It is suspected that nocturnal sudden death in MSA patients is caused not only by abnormal respiration resulting from impairment of the respiratory center, but also by glottic obstruction caused by sputum or by edema of the vocal folds. We recommend tracheotomy when loud laryngeal snoring occurrs in patients with MSA, even if they do not complain of dyspnea while awake.
Obstructive sleep dyspnea (OSD) is a breathing disorder during sleep, which includes snoring and obstructive sleep apnea syndrome. Forty nine adult patients who had been diagnosed as having OSD underwent polysomno-graphic diagnosis with multiple barosensors to find the site of obstruction. OSD was classified into three types; the soft-palate type, root-of-tongue type and combined type. The soft-palate type accounted for 50%, the root-of-tongue type 31.6% and the combined type 18.4%. The effectiveness of UPPP (uvulopalatopharyngoplasty) had been 50-80%, similar to our data for the soft-palate type. The patients for whom UPPP was not effective perhaps had an obstruction in an area other than the soft palate. Ten patients whose site of obstruction was at the root of the tongue underwent midline glossectomy. Preoperative and postoperative results of polysomngraphy showed that the absolute mean value of intraesophageal pressure decreased from 52 cmH2O to 24.2 cmH2O, and the mean value of AHI (apnea hypopnea index) decreased from 61.8 to 29.1. The correct diagnosis of the obstructed area and the selection of the operative method most appropriate for the area very important. Midline glossectomy is the most effective treatment for the root-of-tongue type of obstruction.
I examined 43 patients with abnormal sensation in the pharynx (ASP) from 1987 to 1989. I assumed that the cause of ASP was related to nasal allergy and/or allergic nasopharyngitis. Using fiberscopy, I found nasal allergy in 37 of the 43 ASP patients (86%), and I found redness of the nasopharynx in 35 of the 37 (94.4%). On the contrary, redness of the nasopharynx was seen in only 16 of ASP patients without nasal allergy 31 (51.7%), and this redness was very mild. In addition, the following findings seem to be extremely important in learning about the cause of ASP. 1. the effectiveness of nasal DSCG spray was effective in 19 of 23 patients with ASP (82.6%) (P<0.01); 2. the anesthetization for pharynx caused disappearance of the ASP (according to Yamagiwa's report). It is my conjecture that the cause of ASP is mainly contraction of the upper part of the esophagus which results from parasympatic nerve stimulation caused by the allergic inflammation in the nasopharynx. From the point of view of “Chuigaku”, ASP mostly follows “Kansyo” as well as nasal allergy, while “Zinkyo” is no related to it. “Shoseiryuto” was effective in the treatment of ASP.
Three cases of carcinoma of the base of the tongue are reported and the selection of treatment is discussed. 1. A 63-year-old woman, presented with swelling of the right side of the neck. Cancer of the base of the tongue was found. UICC TNM Classification was T2N2aMO. Radiation was delivered to the lesion and the neck in a dose of 60Gy. The tumor disappeared promptly. 2. A 48-year-old man complained of bloody sputum from a swelling of the tongue base. Excisional biospy was done, and the pathological diagnosis was squamous cell carcinoma. The clinical classification was T2N0M0. The patient underwent radiotherapy in a dose of 56Gy delivered to the local region, and the tumor disappeared. 3. A 61-year-old man complained of swelling of the right side of his neck. Magnetic resonance imaging revealed a mass deep in the base of the tongue. The clinical classification was T2N3M0. The cancer disappeared soon after radiation treatment. These 3 patients have shown no evidence of local recurrence or regional metastasis during follow-up periods ranging from 2 years and 5 months to 4 years and 5 months. Our experience and our review of the literature suggest that surgical treatment may result in severe impairment of swallowing and speech, while radiotherapy may preserve function but may not effectively control advanced disease. Therefore, we conclude that radiation treatment is more effective than surgical treatment in the local control of T1 and T2 cancers of the base of the tongue.
An 87-year-old female complaining of dyspnea and dysphagia was admitted to our hospital in December, 1990. Physical examination revealed marked swelling of the tongue and submental area without pain or itching. Endoscopically, edematous swelling of the mucous membranes was observed in the pharyngeal and laryngeal regions. Initially, we considerd hereditary angioneurotic edema related to complement factors. However, the diagnosis was revised to Quincke's edema (nonhereditary angioneurotic edema) because of the absence of a family history or abnormal complement factors. Blood serum teste including IgE RIST and IgE RAST (HD, mite, pollen and various foods) were within normal ranges. Dyspnea, dysphagia and edematous swelling of the mucous membranes were reduced by the administration of antihistamines and steroid hormones. Because these medicines were effective in decreasing such attacks, some allergic factors were assumed to be present.
Two patients underwent maxillary reconstruction following cancer excision. In each case a triple paddled rectus abdominis musclocutaneous free flap was used. With this flap we could reconstruct the nasal lateral wall, palate defect and cheek surface. To prevent drooping of the flap into the oral cavity the palatal side of the flap was slung of the infraorbital bone under strong tension with the palmalis longus tendon. Since the operation the arch of the reconstructed palate has been maintained. This method is usefil to prevent the drooping of the flap after reconstruction with a triple paddled rectus abdominis musculocutaneous free following maxillectomy.
Retropharyngeal abscess has become a rare disease. We recetly treated a 43-year-old man with retropharyngeal abscess, and a variety of symptoms; a history of meningitis, retropharyngeal swelling, lymphnode enlargement on the left side of the neck, reduced mobility of the left arm, paralysis of the abducens nerve, and sepsis. After per oral incision, his symptoms gradually decreased, and after 3 months almost all of symptoms improved.