下咽頭異物摘出後に生じた下咽頭・頸部食道狭窄を,頸部の局所皮弁を用いた皮膚管による再建(Wookey法)後34年を経過して吻合部に高度の再狭窄を来した1症例に対する治療経験を報告した。症例は42歳の男性で,食物の通過障害を主訴に1995年10月16日当科を初診した。右反回神経麻痺を認め,食道透視検査で,吻合部に高度の再狭窄を認めた。　1995年11月28日,喉頭を保存し,皮膚管を切除し,遊離空腸を用いて下咽頭・頸部食道を再建した。誤嚥防止のため,Billarのlaryngoplasty(喉頭蓋管形成術)を併施した。術後,誤嚥なく常食の経口摂取が可能となり,音声機能も保存された。

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気管・気管支の悪性腫瘍の非根治症例に対し, 気道確保, QOLの向上を目指したステント治療例が急増している。一方, 外傷や熱傷などによる非腫瘍性狭窄に対し, レーザーでの狭窄部切除やシリコンT-チューブの挿入にて気管内腔の確保を行い, 続いて軟骨や皮弁などでフレームを形成する方法が一般的であった。しかし, 生命に重大な影響は与えないが, 治癒までに長期間を要し患者に苦痛を与えている。
同様に, 食道狭窄に対するステントの開発も進み, 近年保険適用も拡大している。Plummer-Vinson症候群による狭窄の鉄剤無効例や遊離・有茎皮弁の吻合部狭窄など, 非腫瘍性の食道狭窄では拡大手術の選択が難しい症例も多く, 治療を遷延させてきた。
気道・食道狭窄に対し種々のステント治療を試み, その利点・欠点についてさまざまな経験をしたので解説した。

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気管切開後の致命的な合併症の一つに気管腕頭動脈瘻がある。一次止血が適切に行われなければ，ほとんどの症例で大量出血あるいは窒息といった転帰を取る。今回，偶然にもカフ付カニューレで一次止血ができ，その後根治的止血を行い救命し得た症例を経験したので報告する。本例では挿入していたカニューレのカフ圧を追加することで一次止血を成し得た。一次止血時のカフ圧は120mmHgを超えていた。しかし，このような合併症を回避するには出血の兆候を見逃さないことと気道の感染をコントロールしつつ，気管内肉芽を予防するためにもカニューレなしの状態で管理することが望ましいと思われる。

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The therapeutic procedures with Celestin dilator were performed on postoperative strictures of the Hypopharynx and Esophagus. Twenty trans-oral dilatation procedures were performed on 9 patients with esophageal strictures.
For the case of the hypopharyngeal and esophageal stricture, success rates for this technique averaged 77.7% defined as the resolution of dysphagia and besides X-ray examination showed obviously the dilatation. Efficacy of the dilatation was influenced by the local condition of disease, but strictures with a diameter as small as 4 mm and as long as 12 mm could be fully expended with a single treatment. With multiple applications, these procedures can be extended to treat strictures with a diameter of 2 mm and a total length of up to 22 mm. In one of the nine patiants, there was a complication of a small perforation in the postoperative suture, but it naturally closed one week late. It is cosidered, that in this case, the procedure was performed too early after operation. If the procedure is performed at least 30 days after operation, and the stricture isn't excessively dilated, it will be possible to avoid complications.
The procedures with Celestin dilator can be safely and easily applied to esophageal strictures of a variety of causes, with a high degree of clinical success. Celestin dilator treatment for the hypopharyngeal and esophageal strictures must, however, be coupled with appropriate medical management to optimize the clinical response.

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　トンネル建設工事における情報化施工の一つとして数値解析を用いた逆解析がある．逆解析は，地山や支保部材の挙動を，詳細かつ定量的に表現することができるため，メカニズムの把握，対策工や施工方法の検討において強力な設計ツールとなる．
　本研究では，粒子群最適化（Particle Swarm Optimization：PSO）による最適化手法と有限差分法を組み合わせた比較的簡易な逆解析手法によって，非線形構成則の地山物性値や地山初期応力に関する複数のパラメータを同時に推定することを試みた．
　本稿は，その初期段階として，数値シミュレーションによる本解析手法の妥当性確認と問題点について報告するものである．

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Our study involves the retrospective investigation of two groups of patients that were treated at our hospital between 1987 and 1996. The first group consists of thirty-six cases of T3 and T4 laryngeal cancer. The second group consists of thirty cases of T3 and T4 hypopharyngeal cancer. Total laryngectomy and total pharyngo-laryngo-esophagectomy were performed on 24 of the first group and on 15 of the second group. The five-year survival rate were 61% and 44% respectively. Complete remission cases with chemotherapy and radiation therapy were five cases and four cases respectively. Local recurrence occurred in 2 cases of laryngeal cancer and cervical lymph node metastasis occurred in a case of hypopharyngeal cancer. The remaining cases of laryngeal preservation showed tumors were highly responsive to chemotherapy and radiation therapy and that vocal cord paralysis disappeared after 40 Gy irradiation.

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　気道狭窄の原因には鼻・咽頭疾患, 喉頭疾患, 気管・気管支疾患, 異物症などが挙げられる. 成人の声門下狭窄の原因疾患は急性声門下腔炎, 喉頭ジフテリア, 喉頭浮腫, 喉頭腫瘍, 喉頭外傷である. 頸部気管狭窄の原因疾患は気管形成不全, 気管軟化症, 結核罹患後の瘢痕, 気管外傷, 気管内肉芽, 気管腫瘍, 外側からの圧迫などである.

　炎症性疾患はその程度により気管切開などの気道確保を行い, 抗菌・消炎治療が中心となる. 外傷のうち内損傷は長期の気管内挿管による肉芽形成や, 気管軟化症となり内腔が保持できなくなる. 外損傷は交通外傷が多い.

　瘢痕性の狭窄に対する治療法としては内視鏡下のバルーン拡張や, レーザーでの狭窄切除を行うが再狭窄の可能性が高く, 何らかの内腔保持が必要となる. 狭窄病変の範囲が長い例には喉頭截開術を行って内腔の瘢痕切除術を行い, 残った気管と皮膚を縫合して喉頭気管溝を形成する. 内腔の面積が大きく取れない時は粘膜や軟骨の移植を行う. さらに内腔の保持のためシリコン製の T チューブを留置し, 二期的に気管前面を皮膚や肋軟骨, 鼻中隔軟骨を移植し形成する. 近年大森らは, ポリプロピレンメッシュとコラーゲンスポンジを用い, 生体内で組織再生を誘導する再建技術を開発した. イヌを用いた動物実験で安全性を確認した後に, 2002年より気管の再生医療を開始している.

　腫瘍性の狭窄は原因疾患治療が中心となるが, 外科的摘出により気道壁が大きく欠損すると, 再建・形成手術の適応となる. さらに根治が望めない症例では内腔保持のため各種のステント治療が試みられる. 気管壁が75%以上欠損すれば, 気管の端々吻合の適応となる. 約 4cm までの欠損であれば可能とされる.

　呼吸器科の分野では気管狭窄に対し人工ステントを使用することが多い. Dumon ステント, Expandable Metallic stent, AERO 気管・気管支用ハイブリッドステントを紹介する.

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喉頭癌に対する治療法は声門部癌, 声門上癌, TNレベル, 腫瘍発育形態, その他を考慮して治療選択され, 5年生存率は他臓器癌に比してはるかに良好である。しかし, 頸部リンパ節転移例は予後不良の例がある。そこで, 1986年9月より1996年12月迄に当科で加療した喉頭癌192例のうち, 治療時すでに両側の頸部リンパ節転移陽性N2c例 (7例) や, 喉頭全摘術と併せ行った頸部郭清術によって両側頸部リンパ節転移陽性であったpN2c症例 (5例) を取り上げ, 臨床的に検討した。すべて supraglottis であり, 1例は multicentric であった。放射線単独治療はT1, T2例2例に対し施行され, 1例に頸部郭清術が施行され, 共に非担癌生存 (NED) である。他は喉頭摘出, 両側頸部郭清術が施行された。加療後pN2c例は5症例すべてT4症例であり, 内4例に術後照射が行われた。予後は遠隔転移死5例, 他癌死1例であった。
T1, T2の一部の例を除いて予防的郭清術は重要で, supraglottis T4症例に対する両側頸部郭清術は徹底すること, 術後照射は意義があると考えられた。遠隔転移対策がさらなる治癒率向上のためには検討課題である。

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喉頭原発の軟骨肉腫は，非常に稀な軟骨腫瘍である。治療としては，腫瘍の大きさに応じて喉頭全摘術，喉頭截開術，内視鏡下摘出術が施行されてきた。
今回，われわれは稀な輪状軟骨原発の軟骨肉腫症例を経験したので報告した。症例は55歳男性，主訴は嗄声である。初診時に喉頭内視鏡検査で粘膜下腫瘍を指摘された。CT検査では，輪状軟骨に高吸収域と低吸収域が混在する腫瘤影を認めた。
当初，喉頭の良性腫瘍を疑い，喉頭顕微手術および前頸部からの外切開により輪状軟骨と第1～第5気管輪の生検術を施行したところ，病理組織の結果は軟骨腫を疑った。全身麻酔下に外切開にて腫瘍切除術および気管切開術を施行した。永久病理標本では軟骨肉腫と診断した。患者に喉頭全摘術を勧めたが，本人が根治手術を希望せず，追加治療を施行しなかった。術後1年半経過したが，再発していない。今後，厳重な経過観察が必要である。

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We encountered a case having cutaneous neurofibromatosis associated with intestinal leiomyosarcoma and hypopharyngeal carcinoma. The patient was a 57-year-old female, who was hospitalized at Dokkyo University Hospital in September 1993 complaining of dysphagia. Various tests were made, and a tumor was found at the posterior wall of the right piriformis sinus. As a result of a punch biopsy from the hypopharynx, the patient was diagnosed as having “well-differentiated squamous cell carcinoma. ”By radiotherapy of the hypopharynx, her general condition was temporarily improved, but she underwent an operation for a recurrence of the dysphagia on May 30, 1994. Histopathologically, a three-tumor duplication was found after the operation. This consisted of cutaneous neurofibromatosis, leiomyosarcoma of the small intestine and well-differentiated squamous cell carcinoma of the hypopharynx. Tumor duplication is often seen in neurofibromatosis. Careful observation of patients with von Recklinghausen's disease is necessary.

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we reported aggressive treatment for patients with Stage III and IV laryngeal carcinomas based on our study of the records of 89 consecutive patients (previously untreated) who presented stage III and IV carcinomas of the larynx in the period 1975-89.Of these, 53 were stage III patients and 36 were stage IV, and the histological diagnosis in every case was squamous cell carcinoma. The average age of the patients was 66.2 years, and the male-female ratio was 9 to 1.
In the advanced laryngeal carcinoma, the incidence in the cases of supraglottic carcinoma (47/89, 52.8%) was higher than in the cases of glottic carcinoma (37/89, 41.6%). Thirty-one of the 47 cases of supraglottic carcinoma (66.0%) had metastasis to the jugular lymph nodes.
The 5-year cumulative survival rate, viewed by stages, was 63.8% for stage III glottic carcinoma, 74.4% for stage IV glottic carcinoma, 60.9% for stage III supraglottic carcinoma and 40.0% for stage IV supraglottic carcinoma.
Initial examinations revealed metastasis to the jugular lymph nodes in 41 cases. Prognosis was poor, with the 5-year cumulative survival rate for these cases (47.5%) lower than that for the 48 cases without metastasis (66.3%).
Twenty of the 89 cases of advanced laryngeal carcinoma were classified as poorly differentiated squamous cell carcinoma, and the 5-year cumulative survival rate for these (33.1%) was definitely lower than for that the well differentiated types (69.4%; P<0.05).
We conclude that wide resection with complete neck dissection, including irradiation and chemotherapy, is indicated for stage III and IV laryngeal carcinomas-particularly in patients who have supraglottic stage IV tumors with poorly differentiated squamous cell carcinoma. Adjuvant and neo-adjuvant chemotherapy should be administered to prevent lung metastasis, which is the most recurrent form of cancer.

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A case of chondrosarcoma of the larynx is reported. A 77-year-old man consulted our clinic with hoarseness and mild dyspnea. Bilateral vocal cords were fixed at the paramedian line. Magnetic resonance imaging (MRI) and computed tomography (CT) demonstrated a mass arising from the cricoid cartilage. Biopsy was performed and the histological examination demonstrated low grade chondrosarcoma. Basis on these findings and clinical symptoms, we performed total laryngectomy. Fifteen months after surgery, there is no any evidence of recurrence.

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A sixty-year-old male slipped down from a silkworm trellis to an iron pole. His front neck was injured at that accident. On his visit to a local doctor, the neck wound was sutured primarily. In a short time, his neck became swollen, so that the wound was reopened by a surgeon in a different clinic. When the patient was referred to our clinic by the surgeon, 4 hours had passed since the first treatment was done.
Clinical examination revealed the partially defected epiglottis, the lacerated hypopharyngeal mucosa and the fractured hyoid bone. X-ray examination and CT revealed subcutaneous emphysema and tracheotomy was recommended. After tracheotomy was done under local anesthesia, the patient was operated on to repair the epiglottis and the hypopharynx. The left vocal cord was fixed for 3 months after surgery probably due to intubation for the general anesthesia. He was discharged after 44 days of hospitalization.
This case suggest that the first 4 to 5 hours after injury with intensive observation of the patient are the critical period for successful treatment.

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We have treated 159 patients with laryngeal cancer over the past 15 years (Jan. 1, 1977 to Dec. 12, 1991). Of these 159 patients, 14 suffered from T3 glottic carcinoma and 13 from T3 supraglottic carcinoma; the histological diagnosis in every case was squamous cell carcinoma. The average age of the patients was 63.3 years and the male-female ratio was 13 to 1. The 5-year cumulative survival rate was 77.9% for T3 glottic carcinoma and 23.1% for T3 supraglottic carcinoma. Among the cases of glottic carcinoma, 6 patients underwent total laryngectomy. Five patients were treated by total laryngectomy and radiation, and 3 patients received radiation only. We were able to achieve primary site control in 10 of 14 cases. Among the cases of supraglottic carcinoma, 3 patients underwent total laryngectomy, 8 patients were treated by total laryngectomy and radiation, and 1 patient received radiation only. We were able to achieve primary site control in 5 of 8 cases who received laryngectomy and radiation, but were unable to in patients treated with laryngectomy without radiation therapy. Recurrences were found to appear more in cervical lymph nodes in both glottic and supraglottic carcinomas. In 13 cases with supraglottic carcinoma, 7 patients had recurrences sites in cervical lymph nodes. We concluded that elective neck dissection may be indicated for the treatment of T3 supraglottic laryngeal carcinoma.

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