[Follow-up of dysphagia in the elderly--clinical survey of deglutition disorder at a private ENT office].

In a one-year-plus follow-up study in 17 of 26 cases involving apparent liquid aspiration during videoendoscopic screening, subjects were instructed in swallowing using video images and in choosing food, utensils, and posture. The amount of sputum decreased in 10 case (59%), and sputum sticking in the throat disappeared in 4 (18%). Body weight also increased in 4 (24%). Choking coughs noted in 11 during initial videoendoscopy disappeared in 2 (18%). We thus, concluded that detecting dysphagia symptoms early and providing follow-up could help prevent aspiration pneumonia.

[Screening test is for dysphagia in the elderly].

In screening tests for dysphagia conducted using videoendoscopy in 81 subjects over 75-years-old apparent liquid aspiration was found in 26 (32%). In 2 of these 26 saliva aspiration was observed. Logistic analysis of aspiration versus clinical symptoms, including endoscopic findings, showed a significant correlation between aspiration and longer time required for meals, bending forward during swallowing, choking during meals, hypoesthesia of the larynx, delayed swallowing reflex and difficulty in spitting. Results were considered clinically significant although they did not appear to fully agree with those of previous studies. The usefulness of videoendoscopy was confirmed.

Chemosurgery with trichloroacetic acid for allergic rhinitis: evaluation of the efficacy in terms of inhibition of Th2 cell infiltration.

OBJECTIVE: To examine local inhibition of Th2 cell infiltration as the basis for demonstrating the superior clinical effect of trichloroacetic acid (TCA) treatment for allergic rhinitis. METHODS: Mirror-image sections of the inferior turbinate mucosae of both sides were obtained from 26 patients who underwent TCA treatment on one side because of the nasal anatomy status and who eventually underwent bilateral inferior turbinectomy because of failure of the TCA treatment. Th2 cell counts, defined as counts of cells positive for anti-CD4 antibody and anti-CKR4 antibody (double-positive cells) were obtained for comparison. The differences between the TCA-treated and non-TCA-treated mucosae were analyzed by Mann-Whitney's U test. RESULTS: Th2 cell infiltration was characteristically found just beneath the epithelium and in the periglandular areas. The mean count+/-standard deviation of Th2 cells was 4.96+/-2.72 cells/mm(2) in the TCA-treated mucosae and 12.03+/-7.19 cells/mm(2) in the non-treated mucosae, the difference being significant (p<0.01). CONCLUSION: TCA treatment induces inhibition of Th2 cell infiltration. This corroborates the suggestion that TCA treatment can inhibit local type I allergic reactions.

Long-term result of the new endoscopic vocal fold medialization surgical technique for laryngeal palsy.

OBJECTIVE: The conventional surgical method for a case of unilateral laryngeal nerve paralysis with large glottal gap requires an external cervical incision. In the present study, we developed an endoscopic technique of vocal fold medialization that can make the external incision unnecessary. This procedure of autologous transplantation of fascia into the vocal fold (ATFV) was developed for the successful treatment of unilateral laryngeal nerve paralysis. However, the method seemed to be effective only for patients with a relatively mild glottal gap. STUDY DESIGN AND METHODS: In the present study, we modified the method of medialization using the ATFV technique to obtain effective closure of a large glottal gap. To overcome this difficulty, an attempt was made to extend the site of transplantation more posteriorly so as to adduct the vocal process of the arytenoid cartilage in the body of the vocal fold. RESULTS: This new technique was applied to eight cases of patients with unilateral laryngeal paralysis with severe dysphonia. None of the patients showed any evidence of falling off of the graft. Elongation of the maximum phonation time and a decrease in airflow rate during phonation were obtained with improvement in voice quality in all patients 1 year after the surgery. CONCLUSIONS: This method, with its less invasive approach, proved to be useful for the treatment of large glottal gap due to unilateral laryngeal nerve paralysis.

Successful treatment of concurrent chemoradiotherapy for stage I nasal NK/T cell lymphoma: a report of two cases.

Nasal natural killer/T cell (NK/T cell) lymphoma is a rare subtype of lymphomas, being a subtype of non-Hodgkin's lymphoma with a much worse prognosis than other subtypes. One reason for this worse prognosis is that nasal NK/T cell lymphoma is resistant to standard sequential chemoradiotherapy. Thus, we adopted concurrent chemoradiotherapy using a CHOP-like regimen for treating stage I nasal NK/T cell lymphoma. Case 1 was treated with concurrent chemoradiotherapy using 41-Gy irradiation with 12 cycles of the CHOP-like regimen (THP-CVP). Case 2 was treated with concurrent chemoradiotherapy using 50-Gy irradiation with 10 cycles of THP-CVP. In both Case I and Case 2, the tumors disappeared after chemoradiotherapy. The Case 1 patient is still alive with 45 months free of relapse. The Case 2 patient is also still alive with 39 months free of relapse. These results suggest that concurrent chemoradiotherapy using a CHOP-like regimen for stage I nasal NK/T cell lymphoma provided sufficient dose intensity and may be a useful treatment option.

Endoscopic vocal cord medialization: a new surgical technique without neck incision for laryngeal palsy.

Different types of surgery have been reported for glottal insufficiency due to unilateral vocal cord paralysis. We recently developed a new surgical technique of fascia implantation known as vocal cord medialization. This new method achieves a wide glottal gap during phonation, without the use of an external approach. This new technique is described in detail herein, together with the satisfactory results we obtained in six cases of unilateral vocal cord paralysis with a wide glottal gap during phonation. We recommend this technique in cases of unilateral vocal cord paralysis in which both a satisfactory clinical result and an aesthetically pleasing cosmetic result are required.

A study of the effectiveness of chemosurgery with trichloroacetic acid for Japanese cedar pollenosis in terms of the chemical mediator levels in the nasal discharge and results of nasal provocation testing.

OBJECTIVE: The purpose of the present study was to investigate the effectiveness of chemosurgery with 80w/v% trichloroacetic acid (TCA) for the treatment of Japanese cedar pollenosis. The effectiveness of this treatment was evaluated in terms of the levels in the nasal washings of the chemical mediators histamine and eosinophil cationic protein, and the reactivity in the nasal provocation test. METHODS: Patients of cedar pollenosis were divided into two groups, the TCA-treated group (n=90) and the group that was not treated with TCA (nonTCA-treated group) (n=79), according to whether or not they received TCA treatment. In both the groups, the levels of the two aforementioned mediators in the nasal washings were measured during the pollen dispersal season. In addition, allergen provocation tests were performed using the disk method in volunteers from both the groups during the non-pollen dispersal season. The results of the above two determinations were compared statistically between the two groups. RESULTS: The results revealed significantly lower levels of the two mediators in the TCA-treated group than in the nonTCA-treated group (p<0.01). There was also a greater tendency for the subjects in the TCA-treated group as compared to those in the nonTCA-treated group to show negative reactivity in the allergen provocation test (p<0.01). CONCLUSION: Regional suppression of the allergic reaction to Japanese cedar pollen appears to occur as a result of chemosurgery with TCA performed as a day surgery.

[Change of reactive small round cell infiltration in the stroma after pre-operative 8 Gy irradiation using treatment to maxillary sinus carcinoma with Kitasato method and prognosis according to the change].

PURPOSE: In this paper, we report the results of studying the degree of reactive small round cell infiltration in the stroma as a prognostic indicator of maxillary sinus carcinoma treated with the Kitasato method and the effect of preoperative irradiation at 8 Gy on infiltration in the stroma. SUBJECTS: Out of 74 patients who had been treated with this method in the 27 years from 1976 to 2002, the following patients were enrolled in this study: (1) 17 patients from whom tissue specimens could be obtained with biopsies or probe antrotomies before preoperative irradiation, and (2) 40 patients from whom tissue specimens could be obtained after preoperative irradiation including those who survived five years and who died of a specific cause. METHOD: We classified the pattern of distribution of small round cell infiltration in the stroma into three degrees. (1) Stromal infiltration was compared before and after the operation to recognize the prognosis for each patient based on the pattern of distribution of small round cell infiltration in the stroma. (2) The correlation between the degree of stromal infiltration and prognosis was studied statistically. RESULTS: (1) Both the patients with increased stromal infiltration and those postoperatively preserving a preoperative score of 2+ with irradiation at 8 Gy had a good prognosis. (2) The five-year survival rate for patients was significantly higher in those with a score of 2+ for their tissue specimens. CONCLUSION: The Kitasato treatment method is effective and improves the QOL of patients with maxillary sinus carcinoma. The prognosis was good in the patients with increased or preserved stromal infiltration. The low-dose irradiation and chemotherapy used in combination seemed to be biological response modifiers.

[Use of YAG laser combined with mucosal suturing for the treatment of polypoid vocal cord].

To improve low-pitched voices in cases with polypoid vocal cords, YAG laser irradiation combined with a mucosal suturing technique was attempted in 9 female cases with severe polypoid changes in their vocal cords. A YAG laser beam (5 to 10 W) was used to irradiate the upper surface of the polypoid vocal cord. The polypoid content of the cord was gradually coagulated, and the free edge of the cord appeared to slide up toward the burned area. The polypoid content was then removed and squeezed through an open wound made in the burned area using a conventional method. Bleeding was successfully controlled using the laser. After the excessive mucosal margin was trimmed and the contour of the vocal cord was adjusted, the wound was closed by 7-0 monofilament absorbable suture. Suturing was relatively easy because the mucosal edge was also coagulated. Postoperative evaluations of voice quality revealed an improvement in the GRBAS scale of voice quality as well as an elevation in voice pitch and an upwards shift in the voice range in all cases.

Cemento-ossifying fibroma of maxillary and sphenoid sinuses: case report and literature review.

We report a case of cemento-ossifying fibroma (COF) involving the maxillary and sphenoid sinuses and review the literature in order to study the clinical features, imaging findings and histopathologic characteristics of COF. Special care was taken to distinguish this lesion from cemento-osseous dysplasia (COD). It is almost inevitable that differential diagnosis of COD and COF will be complicated by the fact that some pathologic features are shared by both lesions. A combined study incorporating clinical, radiographic and pathologic findings is important in order to ensure an accurate diagnosis. Postoperative follow-up is essential, especially in cases where incomplete removal of the COF was performed.

Clinical impact of using chemoradiotherapy as a primary treatment for hypopharyngeal cancer.

Eighty-eight patients with hypopharyngeal cancer who received chemoradiotherapy as the primary treatment between 1979 and 1997 were investigated. Forty-six patients who received surgery as the primary treatment were analyzed as a control group. There were no statistically significant differences regarding TN classification, tumor stage, tumor site, age or sex between the radiation and surgery groups. The 5-year cumulative survival rate of primary chemoradiotherapy was 47% and this did not differ significantly from that for the primary surgery group. The larynx was preserved in 74% of cases in the primary chemoradiotherapy group, a far better preservation rate than that in the surgery group. After primary chemoradiotherapy, complete remission (CR) was observed in 59% of cases and the average period of CR was 38 months. Among patients with residual tumor, a salvage operation was employed in 31 cases, 13 patients refused to receive surgery and 8 were inoperable. A salvage operation was performed in 35% of all cases and the 5-year cumulative survival rate was 50%. Based on the 5-year survival, primary CR, salvage and laryngeal preservation rates, we conclude that chemoradiotherapy is a good primary treatment for hypopharyngeal cancer.

Treatment of maxillary sinus carcinoma: clinical results using the Kitasato modality.

The conventional therapeutic regimen for maxillary sinus carcinoma consists of dissection of the maxilla, full-dose irradiation and extensive chemotherapy. However, the results obtained with this treatment are often poor. Even when patients recover, their quality of life is significantly reduced as a result of deformity of facial structures and swallowing and articulation dysfunctions. A retrospective analysis of 68 patients with maxillary sinus carcinoma treated with the Kitasato modality between 1975 and 1999 was conducted. All patients underwent pergingival maxillary sinus surgery combined with pre- and postoperative irradiation therapy with standardized total doses of 16 Gy; the postoperative irradiation was given in combination with regional intra-arterial infusion chemotherapy administered via the superficial temporal artery. All visible tumor lesions were removed where possible in order to preserve or facilitate cellular immunity after surgery. The cumulative 5-year survival rates were 85.7% for Stage II patients, 88.1% for Stage III, 76.6% for Stage IVA and 75.% for Stage IVB.

Carcinoma of the nasopharynx: analysis of treatment results in 91 patients.

The outcome of 91 patients (69 males, 22 females; age range 16-82 years) with nasopharyngeal carcinoma treated in our hospital between 1971 and 1999 was evaluated. Factors that appeared to influence prognosis were assessed using the Kaplan-Meier method. The cause-specific cumulative 5-year survival rate for the entire study population was 61.2%. The 1997 International Union Against Cancer classification was used for disease staging. The 5-year survival rates were as follows: 66.7% (n = 3) for Stage I; 100% (n = 2) for Stage IIA; 90.9% (n = 11) for Stage IIB; 78.8% (n = 25) for Stage III; 53.0% (n = 29) for Stage IVA; 37.5% (n = 16) for Stage IVB; and 20.0% (n = 5) for Stage IVC. The disease-free cumulative 3-year survival rates of the patients classified based on initial therapy were as follows: radiation alone, 50.0% (n = 28); combined radiotherapy and chemotherapy that included an undefined anti-cancer drug, 67.2% (n = 39); combined radiotherapy and chemotherapy that included carboplatin (CBDCA), 92.3% (n = 19). These results showed a statistically significant difference (p = 0.043; log-rank test). Stage IVC patients were excluded from the analysis. We conclude that combined therapy, including chemotherapy with CBDCA, is necessary for the treatment of nasopharyngeal carcinoma. In terms of radiation therapy, a field covering the bilateral cervical regions seemed to produce favorable results, even if cervical node metastasis was not confirmed by palpation at the first hospital visit. Key words: carboplatin, chemotherapy,

Three-dimensional analysis of supracricoid hemilaryngopharyngectomized hypopharyngeal cancer.

The aims of this study were to demonstrate the technical aspects of processing high-resolution three-dimensional (3D) images and to describe the value of this approach for studying partially removed hypopharyngeal cancer. Supracricoid hemilaryngopharyngectomy was conducted in three sinus-type hypopharyngeal cancers as a salvage operation. A histopathologic study was conducted in order to fully examine the resection margin of the surgical specimens and to ensure the credibility of our case selection. The morphological features of each specimen were analyzed and demonstrated using 2D and 3D settings. Whole-mount serial histological sections were developed from the surgical specimens and 3D images were reconstructed based on these sections. In each case the 3D images demonstrated the characteristic patterns of cancer extension, such as superior extension under the intact epithelium and the formation of multiple skip lesions. The overall resection margin was proven to be free of cancer in all three cases. In conclusion, 3D study was useful for evaluating the overall resection margin of surgical specimens and provided valuable information for use in future follow-up. Using this technique, the morphological findings from serial sections are more comprehensive and impressive. 3D reconstruction is and will be a crucial modality for studying the morphological behavior of hypopharyngeal cancer.

Limited surgery for cancer of the larynx and hypopharynx: options and consequences.

We reviewed surgical options for laryngeal preservation (limited surgery) in laryngeal and hypopharyngeal cancers and the consequences of the options. Of 44 patients with laryngeal cancer, 11 (25%) received limited surgery and 33 (75%) received total laryngectomy. The survival rates were 91% for the limited surgery group and 73% for the total (radical) surgery group. Of 31 patients with hypopharyngeal cancer, 7 (23%) received limited surgery and 24 (77%) received total laryngopharyngectomy. The survival rates were 53% for the limited surgery group and 40% for the total (radical) surgery group. The survival rates associated with limited surgery were thus better than those for total (radical) surgery for cancers of both the larynx and hypopharynx. This was attributed to the limited surgery group comprising well-selected patients with confined lesions. Organ preservation surgery should be technically simple, reliable in terms of its functional impact and, above all, should not jeopardize the patient's survival. Supracricoid subtotal laryngectomy with cricohyoidoepiglottopexy or cricohyoido-pexy has great potential for laryngeal preservation and will become the major limited surgery modality for treating cancer of the larynx. Limited surgery, however, needs to be performed with great care and is indicated only for very well-selected patients with cancer of the hypopharynx.

Clinical review of Wegener's granulomatosis.

The prognosis of Wegener's granulomatosis (WG) improved following the introduction of immunosuppressant agents. We, however, still experience some difficult cases that are resistant to treatment. Early diagnosis and treatment may improve the prognosis of WG. We reviewed patients with WG attending the Department of Otorhinolaryngology, Kitasato University Hospital. Of the 13 patients reviewed, 5 are still alive. A definite diagnosis was difficult to make without the presence of certain characteristic features. Recently, cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) has gained importance in the diagnosis of WG and five of our patients were positive for c-ANCA. Close long-term follow-up of WG is recommended: remission was observed in two of our patients and side-effects of the treatment were identified in four.

Detection of epstein-barr virus in nasal T-cell lymphoma.

The close relationship between Epstein-Barr virus (EBV) and nasal T-cell lymphoma (NTL) has frequently been reported. However, the status of the infection, either lytic or latent, is obscure. This study involved 16 patients with NTL. Phenotypes of lymphoma cells were examined by immunohistochemical staining using CD3, CD4, CD8, CD20 and CD45RO monoclonal antibodies. EBV-encoded small nuclear RNA (EBER)-1 and EBV NotI tandem repeat region were detected by reverse transcription, using a rapid (< or = 60 min) in situ hybridization technique. Tumor cells expressed at least one T-cell marker, such as CD3, CD4, CD8 and CD45RO. CD20 was not detected in any of the cases. EBER-1 was identified in all cases; no Notl tandem DNA repeat was demonstrated. All cases demonstrated a T-cell phenotype. These data suggest that NTL is associated with EBV infection in the latent phase.

Head and neck malignancy statistics at Kitasato University.

We analyzed and reported on those patients with head and neck (H&N) malignancies who had visited our university within the last 30 years. The number of H&N patients registered per year has gradually increased with time and approximately 120 new patients have been registered annually in recent years. Age-adjusted morbidity has also increased gradually, from 7.06 to 10.55 per 100,000 citizens, in recent years. The population of Sagamihara city has gradually increased in parallel over the same period. Cancers of the pharynx, larynx and oral cavity are the three major H&N tumors. Squamous cell carcinoma was the most commonly seen pathological diagnosis, followed by malignant lymphoma. The 5-year crude survival rate for all patients was 50%. It is suggested that improving the survival rates of cancers of the oral cavity, nasal cavity and paranasal sinuses should be a prerequisite, in order to diminish H&N tumor deaths in Japan. A satisfactory survival rate for cancer of the paranasal sinuses has been achieved at Kitasato University and it is hoped that our modality will further prevail in the near future. Cancer of the oral cavity is visible and can be detected by a simple clinical examination. As H&N surgeons it is necessary to educate all physicians as to the importance of early detection of H&N tumors. We also need to encourage the public to reduce smoking and drinking in order to prevent a further increase in the number of H&N patients. Our assertions are based on the fact that the number of H&N patients in 2050 is estimated to be three times greater than that at present due to the increase in the population of elderly people (assuming the morbidity rate remains constant). Key words: alcohol, cancer trends, morbidity, predictions, tobacco.

Clinical study of T1a glottic-type cancer.

Laser surgery is indicated for T1a glottic cancer when the tumor is localized in the membranous portion without involvement of the anterior commissure or cartilagenous portion. Treatment for T1a glottic cancer was reviewed with particular attention to indications, prognosis and the pattern of recurrent cases. A group treated with laser surgery showed 5-year local control, larynx conservation and survival rates of 90.5%, 100% and 100%, respectively. Corresponding values for a group treated with radiotherapy were 92.2%, 98.0% and 100%, respectively. In three cases of recurrence, laser surgery was carried out as second and third treatments. These cases met the above-mentioned indications for laser surgery at the time of recurrence and re-recurrence. Of the three patients, two have survived for > or = 6 years without further recurrences. Provided strict selection criteria are applied, laser surgery is indicated in some cases of recurrence.

Clinical review of autopsy cases that succumbed to head and neck malignancies.

We investigated autopsy cases that had succumbed to head and neck malignancies in the light of the relationships between locoregional tumors and distant metastasis, between the frequency and site of distant metastasis and between the occurrence of locoregional tumors/distant metastasis and the cause of death. Of the 203 cases autopsied at the Kitasato University Hospital between 1972 and 1999, 174 had epithelial tumors and 29 had non-epithelial tumors (malignant lymphoma in 20/29). In terms of epithelial tumors, 107 patients (61%) had locoregional disease and 101 (58%) exhibited distant metastases; 39 cases (28%) had distant metastasis without locoregional tumors. Although the cause of death was mostly as the result of locoregional disease, death related to distant metastasis was also frequently observed. Of the 20 cases with malignant lymphoma, 17 had distant metastases and only 2 of them manifested tumors in the primary region. All 17 patients with distant metastases showed tumors in the distant lymph nodes, with a relatively high occurrence of metastasis to the gastrointestinal tract. Key words: cause of death, distant metastasis, locoregional tumor.