鈴木 政美

Retropharyngeal goitre extending to the oropharyngeal level is rare. We present a case of papillary thyroid carcinoma (PTC) with a retropharyngeal cystic goitre extending to the uvular level. A woman in her 50s presented with swelling of the neck and dyspnoea. CT and MRI findings showed a primary tumour in the left lobe of the thyroid gland and a retropharyngeal dumbbell-shaped cystic goitre extending to the uvular level. Total thyroidectomy, central neck dissection and tracheostomy were performed. During the surgery, we opened the retropharyngeal space, and no mass was found. The pathological findings showed that the primary PTC (pT2) was surrounded by benign lesions, including the dumbbell-shaped cystic goitre. We speculated that the dumbbell-shaped cystic goitre extended from the visceral space (VS) into the pharyngeal mucosal space (PMS) and reached the uvular level because the thyroid gland is in the VS, and the VS and PMS are continuous spaces.

Reported postoperative complications of mediastinal goitre include recurrent laryngeal nerve palsy, hypoparathyroidism and tracheomalacia. Voice and swallowing symptoms after thyroid surgery have been associated with laryngopharyngeal reflux, but it is unclear whether the retrograde flow of gastric contents into the oesophagus, larynx and pharynx worsens after thyroid surgery. We present the case of a man in his 40s with gastro-oesophageal reflux disease (GERD) who developed heartburn and laryngeal granuloma after total thyroidectomy for mediastinal goitre. Vonoprazan therapy effectively controlled these symptoms. Although the exact cause remains unclear, we suggest that changes in pressure dynamics after thyroidectomy may worsen the retrograde flow of gastric contents into the oesophagus, larynx and pharynx, contributing to GERD symptoms and laryngeal granuloma. This case highlights the need to consider the management of retrograde flow of gastric contents into the oesophagus, larynx and pharynx in the postoperative care of mediastinal goitre resections.

Squamous cell papilloma with elongated villous projections may occur in the hypopharynx and present with symptoms observable on physical examination.

BACKGROUND/AIM: Lingual lymph node (LLN) metastasis from tongue cancer occurs at four subsites. However, subsite-related prognosis is unknown. This study aimed to analyze the association between LLN metastases and disease-specific survival (DSS) with respect to these four anatomic subsites. PATIENTS AND METHODS: Patients with tongue cancer treated between January 2010 and April 2018 at our institute were reviewed. The four subgroups of LLNs were median, anterior lateral, posterior lateral, and parahyoid. DSS was evaluated. RESULTS: LLN metastases occurred in 16 of the 128 cases; six and 10 cases were identified during initial and salvage therapy, respectively. Zero, four, three, and nine cases were median, anterior lateral, posterior lateral, and parahyoid LLN metastases, respectively. The 5-year DSS of patients with LLN metastasis was significantly poor on univariate analysis; parahyoid LLN metastasis showed the worst prognosis. Multivariate analysis indicated that only advanced nodal stage and lymphovascular invasion were significant survival factors. CONCLUSION: Parahyoid LLNs may require the most caution in tongue cancer. The significance of LLN metastases alone for survival was not confirmed on multivariate analysis.

Inconsistency in the definition of LLNs may be a hurdle in ensuring the accuracy of the evidence. Refinements in the classification of LLNs, based on the fascial anatomy and lymphatic vessels, are warranted.

63歳女性。右顎下部腫瘤、顎下部痛を主訴に他院を受診し、右顎下腺腺様嚢胞癌(T4aN2bM1、M1:多発肺転移)の診断でTS-1の内服治療を受けるもPDであり、セカンドオピニオン目的に当科へ受診となった。当科では根治的治療の適応はなく、緩和的医療の方針とした。放射線治療を行ったところ、原発巣・頸部リンパ節転移は縮小した。一方、肺転移は増悪傾向にあり、PTX+Cmab療法を行ったが、13コース終了時点で左眼球転移、眼窩内に浸潤する右後部篩骨洞転移が認められた。以後、視力低下と視野欠損の予防目的で放射線治療を行い両病変は縮小したが、最終的に肺転移増悪のため眼球転移判明3ヵ月後に死亡となった。

PURPOSE: To assess the efficacy and prognostic factors after superselective intra-arterial chemoradiation (RADPLAT) for maxillary sinus squamous cell carcinoma (MS-SCC). MATERIALS AND METHODS: Prognostic significance of age, gender, T and N factors, gross tumor volume of the primary-site (GTV), total cisplatin dosage, and total cisplatin dosage per GTV (CDDP/GTV) for primary-site recurrence-free survival rate (PRFS) were analyzed. RADPLAT was administered to 27 patients. The median follow-up period was 42.1 months. RESULTS: The 3-year rates of overall survival and PRFS were 59.2% and 53.9%, respectively. In univariate analysis, age, male, and total cisplatin dosage were significant factors for PRFS. In multivariate analysis, lymph node metastasis was significant factors for PRFS, and gender and total cisplatin dosage weakly influenced PRFS. In acute phase, no patient showed ≥ grade 3 hematologic toxicity, and grade 3 mucositis developed in 5 patients. Late toxicities were recognized in 3 patients (grade 2 phlegmon of the face, grade 3 maxillofacial osteonecrosis, and retinopathy). Twelve patients (44%) experienced recurrences. Of them, 8 patients showed recurrence at the primarysite. CONCLUSION: RADPLAT was effective for MS-SCC, with acceptable toxicity. Total cisplatin dosage is suggested to be important for primary tumor control.

BACKGROUND/AIM: We investigated whether laryngopharyngeal reflux (LPR) is a risk factor for radiation-induced mucositis. PATIENTS AND METHODS: This was a retrospective cohort study using our departmental database. The study included patients with stage I or II laryngeal and hypopharyngeal cancers treated with radiation therapy alone between April 2009 and March 2014. Based on endoscopic findings, baseline laryngeal signs were evaluated using the reflux finding score (RFS), and the severity of mucositis was assessed during and after radiation therapy. RESULTS: Fifty-eight patients were enrolled. Thirty-one patients were categorized as high RFS (LPR-likely), while 27 patients were categorized as low RFS (LPR-unlikely). Grade 3 mucositis occurred more frequently in the high RFS group (p<0.042). Furthermore, grade 3 mucositis developed earlier in the high RFS group (p<0.001). CONCLUSION: High RFS (i.e., increased likelihood of LPR) appears to be a potential risk factor for developing severe radiation-induced mucositis.

75歳男。急激な右頸部腫脹を自覚した。甲状腺右葉に弾性軟の結節を触知し、発症経過、超音波所見より右葉結節は腺腫様甲状腺腫の嚢胞性結節内出血と診断した。経過観察の方針としたが、初診2日後に嗄声や嚥下困難感が出現したため再診し、喉頭内視鏡検査で右声帯が固定しており、右反回神経麻痺と診断した。初診5日後に貯留液を吸引したところ、初診21日後には反回神経麻痺の改善を認めた。自覚的に頸部圧迫症状が強いことから、初診36日後に甲状腺右葉切除術を施行した。右反回神経を温存し、右葉切除して甲状腺右葉結節を摘出した。病理組織所見では出血を伴う大きな嚢胞を認め、種々の大きさの濾胞を形成する腺腫様甲状腺腫の診断であった。

Presently, the relationship between laryngopharyngeal reflux (LPR) and radiation-induced mucositis has not been fully explored. In the present study, we report 2 cases of laryngeal cancer in which radiation-induced mucositis ameliorated after proton pump inhibitor (PPI) administration. Case 1 was diagnosed with T1aN0M0 right glottis carcinoma and was treated with radiation therapy. Grade 3 mucositis occurred after administration of 46Gy irradiation. PPI was administered and mucositis ameliorated quickly without cessation of radiation therapy. Case 2 was diagnosed with T2N0M0 supraglottic cancer and was treated with concurrent chemoradiation therapy. Grade 3 mucositis occurred after administration of 44Gy irradiation. PPI was administered and mucositis ameliorated quickly without cessation of chemoradiation therapy. In both cases, a remarkable therapeutic effect of PPI was observed in the perilaryngeal areas including the epiglottic vallecula, arytenoid, and postcricoid area. In both cases, LPR involvement was suspected before the onset of radiation therapy. The two cases presented here, indicated a causal relationship between LPR and radiation-induced mucositis. In cases of severe mucositis in the perilaryngeal area in patients with LPR prior to radiation therapy, PPI administration may be an effective therapeutic option.

OBJECTIVE: To assess the efficacy and safety of a single administration of vitamin D3 for postoperative hypoparathyroidism. PATIENTS AND METHODS: Twelve patients with postoperative hypoparathyroidism were enrolled for this study. They had taken calcium and vitamin D3 orally after the surgery and had shown no symptoms of hypoparathyroidism. Then, all patients had changed their regimen to a single administration of vitamin D3 (1α(OH)D3) with monitoring of serum calcium, urine calcium (u-Ca) and creatinine (u-Cre). The dose of vitamin D3 was started at 2.0μg/day and appropriately adjusted to maintain the ratio of u-Ca and u-Cre (u-Ca/u-Cre) at less than 0.3. The physical findings were carefully checked and the serum intact-parathyroid was also estimated. Those data and physical findings were monitored for at least two years. RESULT: The maintenance dose of vitamin D3 varied from 0.5 to 3.5μg/day, and the mean dose was 2.04μg/day. All patients tolerated changes of regimen without any symptoms of hyper-/hypocalcemia. CONCLUSION: A single administration of vitamin D3 is not only safe but also an easy and cost-effective regimen. This also makes drug control easy and worthwhile both for patients and clinicians. LEVEL OF EVIDENCE: 2c.

Most tumors arising in the nasopharynx are malignant and frequently develop otitis media with effusion (OME). On the contrary, benign nasopharyngeal tumors are very rare, and pleomorphic adenoma, which is a benign mixed tumor of the nasopharynx, is also rarely encountered. We herein report a case of nasopharyngeal pleomorphic adenoma which initially presented as OME. This tumor completely blocked the orifice of the Eustachian tube but was removed by a combination of transnasal and transoral endoscopic resection. A defect in the mucous membrane was covered with polyglycolic acid sheet and fibrin glue. Mucous membrane completely covered the exposed tubal cartilage without adhesion near the tubal orifice. OME and hearing loss completely subsided 3 months after the surgery. She was disease-free 2 years after the surgery. Use of polyglycolic acid sheet could be a feasible mesh for closure of surgical defect without scarring, and it also led to healing of OME.

OBJECTIVE: Stenosis of a permanent tracheostoma after total laryngectomy lowers postoperative quality of life (QOL), and its prevention is clinically important. METHODS: From April 2003 to March 2009, the authors performed 87 permanent tracheostomies. For the purpose of prevention of tracheostomal stenosis, we had applied new technique from October 2005. RESULTS: The incidence of the tracheostomal stenosis was retrospectively reviewed. Until September 2005, conventional permanent tracheostomy was applied for 33 cases and tracheostomal stenosis developed in 6 cases (18.2%). On the other hand, stenosis did not develop in any of the 54 cases in which the new technique was used. The triangular method was significantly superior to the conventional method in preventing stenosis. Stomal recurrence did not develop in either technique. CONCLUSION: The key point of the new technique is as follows: at the upper end of trachea, the posterior part of tracheal cartilage is preserved and the anterior edge of the tracheostoma is made much lower. The shape of the tracheostoma approximates a triangle, and the area is greater than with other methods. From our experience, this technique is safe and effective for the prevention of tracheostomal stenosis.

76歳女。近医にて高カルシウム血症を指摘され、原発性上皮小体機能亢進症と診断された。Caの高値、CTとMRIで左下上皮小体の肥大、99mTc-MIBIシンチグラムで左下上皮小体への集積を認め、全身麻酔下に左下上皮小体腫瘍摘出術を施行した。摘出標本の病理診断は腺腫であった。第1病日に右膝関節痛、2病日に左膝関節痛と発熱が出現し4病日に左膝関節腫脹を確認し、膝関節X線で軟骨石灰化を認めたため偽痛風発作と診断した。第3病日よりロキソフロフェンナトリウム内服を開始して、発熱、膝関節痛と腫脹は改善傾向を示し第7病日に退院した。第11病日の再診時には症状は消失し、現在内科にて経過観察中である。

頭頸部癌治療で生じた皮膚欠損3例に対し、創傷被覆剤材を用いた閉鎖療法を行った。TIMEの改善には適切な判断と処置が必要で、創傷被覆剤ティエールを用い、創傷被覆剤の交換(1度/3〜4日)の他、必要に応じてnecrotomy、生理食塩水による洗浄、過剰肉芽の除去などを行った。抗生物質の使用や消毒は行わなかった。1例は、従来の治療(開創)には治癒傾向を示さなかったが、約2ヵ月後には創部が縮小し、浅い状態となった。2例の上皮化は約1〜2ヵ月であった。3例とも良好な成績を得られ、創傷被覆剤による閉鎖療法は、手軽で負担も少なく有用であると思われた。

78歳男。患者は経口摂取困難を主訴に受診となった。内視鏡所見では舌扁桃と下咽頭入口部の間に突出した隆起を認め、舌扁桃との間に憩室が存在していた。咽頭造影側面像では舌根部に憩室と憩室を形成する突出した後壁が認められた。以上、これらの所見より、本症例は喉頭全摘後に生じた舌根部咽頭憩室と診断し、特別な治療は行わず、全粥および軟菜からの経口摂取を開始した。症状は一過性で、現在は以前と同様に米飯と軟菜を摂取し、視診上、憩室に食物残渣は認めない状態である。尚、咽頭憩室の成因は明らかでないが、これまでの報告から残存下咽頭粘膜の縦一線縫合がその出現に大きく関与していることが推察されている。

喉頭腫瘤性病変で全身麻酔下に生検をし,声帯後部に腫瘤性病変を認めた35例(男34例,女1例)について検討した.病理診断は肉芽腫22例,過角化症4例,過角化症+肉芽腫3例,乳頭腫4例,扁平上皮癌2例で,肉芽腫関連病変が25例,過角化症関連病変が7例,上皮性腫瘍が6例あり,そのうち扁平上皮癌は2例であった.なお,女性1例は乳頭腫であった.初診時の主訴と受診理由は,重複を含めて,嗄声が19例,咽頭痛が7例,のどの違和感が6例,のどに痰がからむが2例,偶然発見されたのが2例であった.病理組織別には,肉芽腫22例では嗄声が13例,咽頭痛が4例,のどの違和感が3例,のどに痰がからむが2例,過角化症4例(重複を含む)では咽頭痛が2例,のどの違和感が2例,偶然発見されたのが1例,過角化症+肉芽腫3例では嗄声が2例,咽頭痛が1例,乳頭腫4例では嗄声が2例,のどの違和感が1例,偶然発見されたが1例,扁平上皮癌の2例では嗄声が2例であった

扁桃周囲腫瘍,急性扁桃炎の口蓋扁桃の形態を確認し,口蓋扁桃の形態と扁桃周囲腫瘍の発症について検討を行った.対象は,扁桃周囲腫瘍29名,急性扁桃炎25名で,退院1週間前後の再診時に口蓋扁桃の形態を有茎性扁桃,埋没性扁桃に分類した.尚,嵌入性扁桃は埋没性扁桃に含めた.扁桃周囲腫瘍では埋没性24名,有茎性5名で,急性扁桃炎では埋没性13名,有茎性12名であり,扁桃周囲で有意に埋没性扁桃が多かった.左右で口蓋扁桃の形態が異なる症例はなかった.扁桃周囲腫瘍で有意に埋没性扁桃が多い理由について推察した結果,結論として,炎症性産物の排泄の障害を来たすと推察される埋没性扁桃のような口蓋扁桃の形態が,扁桃周囲腫瘍の発症に関与している可能性があると考えられた

49歳男.両側扁桃腫脹感,発熱が出現し,抗生剤で解熱したが,扁桃腫脹感は残存し,咽頭違和感を自覚するようになった.両側口蓋扁桃乳頭状肥大症として外来で経過を観察していたが,自覚症状の改善はなく,全身麻酔下に両側口蓋扁桃摘出術を施行した.病理組織所見では,乳頭状肥大部の重層扁平上皮の肥厚,実質内の結合組織の増生,リンパ組織の増生が認められたが,慢性扁桃炎と大差がない所見であった.術後,局扁桃脹感,咽頭違和感は消失した

72歳男.経腸栄養剤エンシュア・リキッドにより肝障害,発熱をきたした.舌癌による舌痛のため経口摂取量が減少しており,恒常的に摂取カロリーが不足した状態で肝臓もそのような状態に適応していたと考えられた.本例はエンシュア・リキッドを中止することで肝障害は改善されており,再開後の軽度肝障害悪化もその後の増量にも拘わらず改善した.経腸栄養剤投与時は肝障害にも十分注意しながら使用すべきである

65歳男.主訴は左頸部腫脹.初診時左胸鎖孔突筋部から後頸三角部にかけて90×70mmの柔らかい腫瘤を触知し,MRI T1強調像で低信号の嚢胞状腫瘤を認めた.画像所見,生検所見から頸部嚢胞状リンパ管腫と診断しOK-432局注療法を施行した.腫瘤は縮小を続け40 日後には触知しなくなった.しかし超音波上はリンハ管腫の残存を認め,MRI画像上55×38×13mmであった.患者は治療効果に十分満足して追加治療を希望しなかった

49歳女.咽頭後間隙魚骨(カレイ)異物の症例.局所所見,画像所見,手術所見から魚骨は,1)左梨状陥凹が腫脹しており,2)画像上,骨様の異物陰影が上方で正中,下方で正中より左側に傾いていた,3)手術で魚骨が咽頭後間隙にあるのを確認した,ことより左梨状嵌凹から下咽頭後壁を貫通し,咽頭後間隙に入り左側→右側上方に向かって侵入したと推測した

27歳男.突然激しい頭痛が出現した.精査の結果,クモ膜下出血と診断し,クリッピングを施行した.術後,気管内挿管を行った.抜管直後,嗄声,嚥下痛を自覚した.嗄声の改善が認められず,当科受診した.局所所見から,左披裂軟骨脱臼と診断した.その後,嗄声,左披裂軟骨脱臼,声門閉鎖不全に軽快傾向が認められた為外来での経過観察とした.嗄声の自覚が殆ど消失し,左披裂軟骨脱臼,声門閉鎖不全も消失し,左披裂軟骨脱臼は自然治癒した

病理組織診断が確定した耳下腺上皮性腫瘍122例の術前症状を検討した. 1)硬度,癒着,疼痛,皮膚発赤,顔面神経麻痺,急速増大傾向の症状の内,癒着,疼痛,皮膚発赤,顔面神経麻痺,急速増大傾向の症状で,良性腫瘍と悪性腫瘍との間に有意差を認めた. 2)悪性腫瘍で原病死例と他病死・生存例の出現症状数を比較すると,原病死例の方が出現症状数が有意に多かった. 3)顔面神経麻痺は予後因子であると考えられた

1) 67歳男,ワルチン腫瘍内に結核感染を認めた。2)結核の感染経路を同定することは困難であった。3) FNA (Fine Needle Aspiration Cytology)は本症例の病態を忠実に捉えておりその有用性を認識した