Unexpected radiation laryngeal necrosis after carbon ion therapy using conventional dose fractionation for laryngeal cancer.

Carbon ion therapy is a type of radiotherapy that can deliver high-dose radiation to a tumor while minimizing the dose delivered to organs at risk. Moreover, carbon ions are classified as high linear energy transfer radiation and are expected to be effective for even photon-resistant tumors. A 73-year-old man with glottic squamous cell carcinoma, T3N0M0, refused laryngectomy and received carbon ion therapy of 70 Gy (relative biological effectiveness) in 35 fractions. Three months after the therapy, the patient had an upper airway inflammation, and then laryngeal edema and pain occurred. Five months after the therapy, the airway stenosis was severe and computed tomography showed lack of the left arytenoid cartilage and exacerbation of laryngeal necrosis. Despite the treatment, 5 and a half months after the therapy, the laryngeal edema and necrosis had become even worse and the surrounding mucosa was edematous and pale. Six months after the therapy, pharyngolaryngoesophagectomy and reconstruction with free jejunal autograft were performed. The surgical specimen pathologically showed massive necrosis and no residual tumor. Three years after the carbon ion therapy, he is alive without recurrence. The first reported laryngeal squamous cell carcinoma case treated with carbon ion therapy resulted in an unexpected radiation laryngeal necrosis. Tissue damage caused by carbon ion therapy may be difficult to repair even for radioresistant cartilage; therefore, hollow organs reinforced by cartilage, such as the larynx, may be vulnerable to carbon ion therapy. Caution should be exercised when treating tumors in or adjacent to such organs with carbon ion therapy.

The relationship between cerebral T2 hyperintensity and fixation suppression of vestibulo-ocular reflex in elderly patients with dysequilibrium symptoms.

OBJECTIVES: To evaluate the relationship between cerebral T2 hyperintensity on MRI and visual suppression of vestibulo-ocular reflex (VOR) in elderly patients with dysequilibrium symptoms. METHODS: Eighty-nine elderly patients with no MRI abnormalities in the infratentorial region aged 60-89 years complaining dysequilibrium symptoms were studied. Cases with whom a definitive diagnosis of peripheral or central disease could be established were not included. T2 hyperintense lesions in the cerebrum: basal ganglia, subcortical white matter and periventricular white matter were evaluated. VOR in darkness and fixation-suppressed VOR using pseudo-sinusoidal rotation stimuli were recorded to calculate visual suppression rate. Correlation between visual suppression rate and semi-quantitative scores for severity of T2 hyperintensity in the cerebrum was investigated. RESULTS: Patients with T2 hyperintensity in the cerebrum exhibited significantly lower visual suppression rate than those without lesions in the cerebrum. Multiple regression analysis showed that visual suppression rate was significantly and negatively correlated with severity of lesions in the basal ganglia, but not with patient age, severity of subcortical white matter lesions, or that of periventricular white matter lesions. CONCLUSIONS: In elderly patients with dizziness with a non-specific history and otoneurological findings, fixation suppression of vestibular nystagmus was associated with T2 hyperintensities in the basal ganglia.

Impaired visual suppression of manually rotated vestibuloocular reflex indicates the need of further evaluation by MRI and MRA in patients with vertigo.

OBJECTIVE: MRI and MRA are accepted as valuable methods for diagnosing vertigo, although they are costly and time-consuming. Thus, some indicator of the necessity of a detailed evaluation by MRI and MRA is desirable. STUDY DESIGN AND SETTING: To assess the usefulness of an impairment of the visual suppression (VS) as an indicator, the relation between abnormal findings on MRI and/or MRA and impairment of the VS of manually rotated vestibuloocular reflex (VOR) was retrospectively examined in 40 consecutive patients suffering from vertigo. RESULTS: 12 of 23 patients with a low VS% were found to have a pathologic condition on MRI and/or MRA, however, no abnormality was found in any of the patients with a normal VS%. The rates of abnormality on MRI and/or MRA significantly differed between the 2 groups (chi2, P = 0.0004). CONCLUSION: The VS% is thought to be a good indicator of the need for further evaluation by MRI and MRA in vertiginous patients.

Reversible bilateral vestibular impairment caused by fourth ventricle epidermoid tumor.

A 26-year-old man presented with an epidermoid tumor of the fourth ventricle manifesting as headache with nausea and vertigo. Neurological examination revealed no cerebellar signs, except nystagmus. Bilateral vestibular impairment was identified by the caloric test. The tumor was removed via the midline suboccipital approach. The bilateral peripheral vestibular function recovered remarkably postoperatively. This marked improvement suggests that the bilateral vestibular impairment was caused by compression of the vestibular nuclei by the tumor.

Hyperviscoelasticity of epipharyngeal mucus may induce globus pharyngis.

Detailed observation reveals a lump of translucent sticky mucus standing in the epipharynx of most globus patients, suggesting that the mucus adherent to the epipharynx causes a globus sensation. The epipharyngeal mucus of 70 consecutive globus patients was sampled via the nasal cavity. Fucose and sialic acid, the determinants of the viscoelasticity of mucus, were measured. Twenty-three patients were also asked to complete the Throat Questionnaire so we could evaluate the correlation between the degree of globus sensation and the viscoelasticity of the mucus. The mucus of 10 healthy subjects was sampled, analyzed, and compared with the data of the patients. The fucose and sialic acid concentrations found in the patients with globus pharyngis were significantly higher than those in the control subjects (Mann-Whitney U test, p < .01). The fucose concentrations correlated significantly with the globus pharyngis scores (Spearman correlation, p < .05). We conclude that there is a close association between stagnant mucus in the epipharynx and globus sensation.

Endoscopic trans-nasal-vestibular approach to the maxillary sinus--application for mucoceles of the maxillary sinus.

Endoscopic endonasal surgery has been applied to the treatment of paranasal mucoceles. The approach is, however, hard to be adopted for maxillary mucoceles when the cyst is situated in the anterior and/or lateral portion of the maxillary sinus, has a thick bony lateral wall of the inferior nasal meatus, and when the patients develop compartmentalized cysts following facial trauma or sinus operation. We devised an endoscopic approach via the vestibule of the nose to reach any part of the maxillary sinus and applied it for the treatment of postoperative maxillary mucoceles, which could not be opened following the usual endoscopic approach with favorable outcomes.