Buccal fat pad flap for transoral repair of radiation-induced necrosis in the lateral oropharyngeal wall.

Soft tissue necrosis (STN) is a late toxicity after radiotherapy. Extensive tissue defects due to STN near the carotid artery, such as in the lateral oropharyngeal wall, may lead to infectious pseudoaneurysms associated with fatal bleeding. Such defects are usually treated with transcervical reconstructive surgeries, which are highly invasive and technically difficult. We report a case in which a buccal fat pad (BFP) flap was used for minimally invasive transoral repair of tissue defects due to radiation-induced STN in the lateral oropharyngeal wall. The BFP flap covered the tissue defect, and the wound epithelialized completely. The patient had no dysfunctional mouth opening, speech, or swallowing. The BFP flap can be easily harvested via a minimally invasive transoral approach and is expected to be further utilized for radiation-induced STN in the lateral oropharyngeal wall.

Long-Term Outcomes of End-Flexible-Rigidscopic Transoral Surgery for Pharyngolaryngeal Cancer.

OBJECTIVE: End-flexible-rigidscopic transoral surgery (E-TOS) is a new and minimally invasive transoral surgery for resection of Tis-selected T3 pharyngolaryngeal cancers. We evaluated long-term oncological outcomes and whether postoperative voice and swallowing function were preserved following E-TOS. METHODS: In this retrospective single-center study, 154 patients treated with E-TOS using a curved retractor, flexible-tip rigid endoscope, and thin curved instruments were included. Their survival rate, larynx preservation rate, and disease control rate were estimated using the Kaplan-Meier method. Postoperative voice function was evaluated using both objective and subjective tests. Postoperative swallowing function was assessed using the Hyodo score and the functional outcome swallowing scale. RESULTS: The 3-year and 5-year overall survival, disease-specific survival, disease-free survival, laryngectomy-free survival, local control, and loco-regional control rates post E-TOS were 89.8% and 82.2%, 95.6% and 92.3%, 78.5% and 70.3%, 87.2% and 80.9%, 93.9% and 92.5%, and 87.2% and 85.7%, respectively. Both objective and subjective postoperative voice and swallowing function tests were within normal limits in more than 90% of the patients. CONCLUSION: E-TOS is an effective, safe, low-cost, and minimally invasive transoral surgery for Tis-selected T3 pharyngolaryngeal cancer; it also preserves postoperative voice, larynx, and swallowing function. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1415-1424, 2023.

Postoperative Intensity-Modulated Radiation Therapy for Myoepithelial Carcinoma in the Parotid Gland.

Myoepithelial carcinoma (MC) is an extremely rare form of tumor, with no standard treatment established to date. Although several reports have discussed postoperative radiation therapy (PORT), few have applied intensity-modulated radiation therapy (IMRT), and none has described the dose and radiation field in detail. In this report, we describe a case of MC of the parotid gland that was treated with high-dose IMRT (70 Gy) after partial resection. The patient, a 61-year-old female, underwent excisional surgery and was diagnosed with MC arising from a pleomorphic adenoma (PA). Postoperative irradiation was administered as 70 Gy in 35 fractions of local radiation. The patient had cancer recurrence in the irradiated field. However, no serious adverse events associated with the radiation therapy have been confirmed, implying that postoperative high-dose radiation therapy may be safely administered via IMRT.

Sensorineural hearing loss and hypoplastic cochlea in Axenfeld-Rieger syndrome with FOXC1 mutation.

OBJECTIVE: Axenfeld-Rieger syndrome (ARS) type 3 is a rare autosomal dominant disease, characterized by anterior segment dysgenesis of the eye, hearing loss, and cardiac defects. ARS type 3 is highly associated with FOXC1 mutations, which induces developmental disorders of neural crest cells. Most studies about ARS patients focused on ophthalmologic findings, but details in their hearing loss have not yet been revealed. In this report, we investigated audiological and otological manifestations in the ARS type 3 patient who had the novel heterozygous FOXC1 mutation leading deletion at the forkhead DNA-binding domain. METHODS AND RESULTS: Pure tone audiometry showed bilateral sensorineural hearing loss (SNHL) and audiological examinations confirmed that major dysfunctions existed in the cochlea, rather than the spiral ganglion neurons and the cochlear nerve. CT and MRI revealed the hypoplastic cochlea at both sides. Given that the 6p25 deletion syndrome, lacking one allele of the FOXC1 gene, shows similar, but more severe cochlear malformations than the present case, the FOXC1 mutations might contribute to the hypoplasia and dysfunctions in the cochlea. CONCLUSION: To our knowledge, this is the first report demonstrating that the ARS type 3 patient with the FOXC1 mutation has the hypoplasia and dysfunctions in the cochlea, which results in bilateral SNHL.

Defect repair with fibrin glue/polyglycolic acid after endoscopic laryngopharyngeal cancer resection.

OBJECTIVES/HYPOTHESIS: In 2013, we introduced a modified technique for mucosal/muscle layer defect coverage with fibrin glue and polyglycolic acid (PGA) sheets (mMCFP technique) in patients undergoing endoscopic transoral surgeries for laryngopharyngeal cancers. This technique allows easy and convenient coverage of the wound surface, even when it involves the laryngopharyngeal lumen. To our knowledge, use of the MCFP technique for coverage of postoperative mucosal and/or muscle layer defects involving the laryngopharyngeal lumen has not been reported. The aim of the present study was to retrospectively evaluate the safety of our mMCFP technique used simultaneously with endoscopic transoral resection of Tis, T1, T2, and select T3 pharyngeal and supraglottic cancers. STUDY DESIGN: A single centre retrospective study. METHODS: Between June 2013 and February 2019, 102 patients underwent simultaneous end-flexible-rigidscopic transoral surgery and wound coverage using our mMCFP technique. All patients required mucosal and/or muscle layer resection. For all patients, we recorded the incidence of postoperative complications and the time period for which the PGA sheets could be observed after surgery. RESULTS: In 41%, 35%, and 8% patients, the PGA sheets could be observed on the wound surface for 2, 3, and 4 weeks, respectively. Other than postoperative bleeding in two patients (2%), no postoperative complications were recorded. CONCLUSIONS: The findings of this study suggest that our mMCFP technique is a safe and simple method for the repair of mucosal and/or muscle layer defects after endoscopic transoral surgery for laryngopharyngeal cancers. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1740-1745, 2020.

Clinical outcomes of end-flexible-rigidscopic transoral surgery (E-TOS) in patients with T1-selected T3 pharyngeal and supraglottic cancers.

BACKGROUND: Endoscopic laryngo-pharyngeal surgery (ELPS), which is a transoral minimally invasive surgery using a gastrointestinal endoscope and a curved laryngopharyngeal retractor, is effective to treat primary lesions of superficial laryngopharyngeal cancers. To extend concepts of ELPS to invasive laryngopharyngeal cancers, we developed end-flexible-rigidscopic transoral surgery (E-TOS) from ELPS by changing a gastrointestinal endoscope to a flexible-tip rigid endoscope. AIMS/OBJECTIVES: To retrospectively evaluate oncological outcomes and laryngopharyngeal functional preservation of E-TOS in patients with T1-selected T3 laryngopharyngeal cancers. MATERIAL AND METHODS: In 47 patients T1-selected T3 pharyngeal and supraglottic cancers were resected by E-TOS using the flexible-tip rigid endoscope and curved instruments. Negative resection margin was histopathologically evaluated. The survival, preservation of larynx, and disease control rates were estimated using Kaplan-Meier method. RESULTS: Curative resection was achieved in 94% of patients. No patient complained prolonged swallowing dysfunction or hoarseness after E-TOS. Postoperative bleeding, stenosis of the pharynx and esophageal entrance, and local recurrence was observed each in one patient. The 3-year overall survival, disease-specific survival, laryngeal preservation, local control, and locoregional control rates were, 86%, 93%, 100%, 98%, and 79%, respectively. CONCLUSION: E-TOS is an effective minimally invasive surgery for T1-selected T3 pharyngeal and supraglottic cancers with preserving laryngeal function.

[Prognosis of Papillary Thyroid Carcinoma with Local Invasion].

OBJECTIVE: The aim of this study was to detect prognostic factors in patients with locally advanced papillary thyroid carcinoma. PATIENTS: The study included 72 patients (T4a/T4b 72/0, N0/N1a/N1b 25/15/32, M0/M1 68/4, mean follow-up 8.1 4.4 years) who underwent initial surgical treatment at Osaka Red Cross Hospital between April 1993 and April 2011. RESULTS: Eleven patients died of PTC, 3 patients with recurrence died of unrelated disease and 10 patients are alive with recurrence. The overall 5-year survival rate was 88.3%, and the 10-year survival rate was 73.4%. The disease-specific 5-year survival rate was 91.4%, and the 10-year survival rate was 88.6%. The 5-year local control rate was 94.1%, and the 10-year local control rate was 85.4%. Patients with distant metastasis (M1), tracheal invasion and/or multiple organs invasion showed a significantly worse disease-specific survival rate based on a univariate analysis, which also revealed that tracheal invasion, laryngeal invasion, esophageal invasion and multiple organs invasion were risk factors linked to the development of distant metastasis during follow-up (recurrence as distant metastasis). The following were found to be clinically significant risk factors, based on the multivariate analysis among tracheal invasion, laryngeal invasion, esophageal invasion and recurrent laryngeal nerve invasion : Tracheal invasion was a risk factor for disease-specific survival, and tracheal invasion and laryngeal invasion were risk factors for recurrence as distant metastasis. CONCLUSIONS: In this study, distant metastasis, multiple organs invasion, tracheal invasion and/or laryngeal invasion were shown to be higher risk factors.

[Evaluation of hearing results after tympanoplasty according to the classification of the development degree for pars flaccid cholesteatoma].

Our surgical treatment for middle ear cholesteatoma is based on the following 2 concepts: (1) Preservation of the physiological morphology and function of the middle ear, that is, maximal preservation of the posterior wall of the external auditory meatus and the middle ear mucosa and (2) Careful resection of the matrix membrane of the cholesteatoma through the continuity of the matrix membrane. In case the cholesteatoma matrix membrane is ruptured, a staged operation should be performed to prevent the development of residual cholesteatoma from the residual matrix. In this study, we classified a total of 238 cases of the pars flaccida cholesteatoma primary operated on Osaka Red Cross Hospital between January 2006 and March 2008 according to the Classification and Staging of Cholesteatoma proposed in 2010. The age of the patients ranged from 4 to 79 years (average: 49.8 years) and there were 123 males and 115 females. Follow up ranged from 1 year to 5 years with a mean follow-up period of 47.8 months. Regarding the stage, 38 (16.0%) ears had stage I cholesteatoma, 155 (65.1%) ears had stage II, and 45 (18.9%) ears had stage III. The successful outcome rate was 97.4% for stage I, 78.7% for stage II and 60.0% for stage III. The rate of the residue and the postoperative recurrence was 2.5% and 4.2%.

Ear-pick injury as a traumatic ossicular damage in Japan.

This retrospective study examined the etiology and treatment results for traumatic, conductive hearing loss in 22 patients who underwent surgery between 1998 and 2008 at Osaka Red Cross Hospital. All patients underwent computed tomography (CT) of the temporal bone preoperatively. The ear surgery comprised closure of the ruptured tympanic membranes and restoration of the sound-transmitting function of the ossicular chain. Their mean age was 30.3 years, and the average delay from injury until treatment was 6.0 years. Of the injuries due to foreign-body insertion, the most common cause was ear-pick injury. Incudostapedial disarticulation was the most common finding, which was diagnosed preoperatively using CT in seven cases and identified at surgery in 15 cases. Closure of the air-bone gap to within 10 and 20 dB was observed in 50.0 and 68.2% of the patients, respectively. The hearing threshold improved by 10 dB or more in 16 (72.7%) patients. If no improvement in hearing loss follows the absorption of hemotympanium or closure of an eardrum perforation, dislocation of the ossicular bones should be suspected. Ossicular reconstruction following trauma produces more stable and better hearing results, even after delayed treatment.

Basic fibroblast growth factor combined with atelocollagen for closing chronic tympanic membrane perforations in 87 patients.

OBJECTIVE: To present the clinical results of closing chronic tympanic membrane (TM) perforations using basic fibroblast growth factor (bFGF) combined with an atelocollagen/silicone bilayer membrane patch. STUDY DESIGN: Closure of TM perforations in 87 patients was attempted using bFGF, which is thought to promote the regeneration of TM tissues by facilitating the growth of fibroblasts and collagen fibers. METHODS: Under an operating microscope, the margin of the perforation was trimmed, and a piece of an atelocollagen/silicone bilayer membrane was placed in the perforation with the silicon layer facing outward and then infiltrated with 0.1 ml of trafermin. Data obtained from patient records included patient age, perforation size, and duration of treatment, with a focus on hearing improvement and complete TM closure. RESULTS: The mean perforation size before treatment was 14.4%. Complete closure of the TM perforation was achieved in 80 patients (92.0%), whereas pinholes remained in 5 patients (8.7%), and small perforations were observed in 2 patients (2.3%). In the patients with complete closure, the TM perforations closed after an average 1.8 treatments, and hearing improved by 13.6 dB. CONCLUSION: This study demonstrated that bFGF combined with atelocollagen is effective for the conservative treatment of TM perforation.

Negative-pressure pulmonary edema after resection of mediastinum thyroid goiter.

Negative-pressure pulmonary edema (NPPE) is an uncommon but life-threatening complication of acute or chronic upper airway obstruction; however, there are few reports of NPPE after giant goiter resection. We report a case with severe NPPE induced by the resection of a mediastinum thyroid goiter. The patient was successfully treated by non-invasive positive airway ventilation (NPPV).

A preoperative sleep study with nasal airway occlusion in pharyngeal flap surgery.

PURPOSE: Obstructive sleep apnea is a major complication of pharyngeal flap surgery. The purpose of the present study is to predict preoperatively the risk of upper airway obstruction after surgery. MATERIAL AND METHODS: We performed an overnight sleep study preoperatively and postoperatively in 16 pediatric patients considered for pharyngeal flap surgery. Preoperative sleep study was done for two nights, once in normal breathing condition and once with complete nasal occlusion by packing of nostril with tampon gauze. RESULTS: In preoperative sleep recordings in normal breathing condition, all subjects had a normal apnea hypopnea index (AHI) less than 5/h. In preoperative recording with complete nasal occlusion, five patients exceeded 5/h in AHI. In particular, for two patients who had AHI higher than 15/h, we gave up a surgery in one case and performed pharyngeal flap operation for the other following a tracheotomy for severe disturbance of oral breathing. The remaining 14 subjects underwent surgery without airway obstructive complications. There was strong correlation between preoperative AHI with nasal tampon gauze and AHI at two weeks postoperatively (r = 0.88 P < .0001). There was no significant correlation between preoperative AHI in normal breathing condition and postoperative AHI (P > .05). CONCLUSIONS: These results exhibit preoperative sleep study with complete nasal airway occlusion represent postoperative breathing condition well during early postoperative period. Preoperative sleep study with complete nasal airway occlusion with nasal tampons could be useful for predicting the risk of upper airway obstruction secondary to pharyngeal flap surgery.

Cricoid regeneration using in situ tissue engineering in canine larynx for the treatment of subglottic stenosis.

The purpose of the present study was to evaluate the efficacy of cricoid regeneration via in situ tissue engineering in a canine larynx for the treatment of subglottic stenosis. As the tissue scaffold, a Marlex mesh tube coated by collagen sponge was used for a rigid airway framework and for tissue regrowth around the tube. On 5 dogs, the larynx was exposed and the anterior third of the cricoid cartilage was resected. The tube was anastomosed to the lower edge of the thyroid cartilage and to the first tracheal cartilage. By postoperative endoscopic examination at 3 to 7 months, no airway obstruction was observed in any of the dogs. There was granulation tissue in 2 dogs and slight mesh exposure in 1 dog, but they were asymptomatic. Confluent regeneration of the epithelium over the scaffold and good incorporation of the scaffold mesh into the host tissue were observed after surgery.

Nerve-muscle transplantation to the paraglottic space after resection of recurrent laryngeal nerve.

OBJECTIVE: To evaluate a new method of nerve-muscle transplantation (NMT) to the paraglottic space after resection of the recurrent laryngeal nerve (RLN) during surgery for thyroid cancer. DESIGN: Review of nine consecutive patients with RLN paralysis caused by the thyroid cancer before surgery. METHOD: After the usual extirpation of the thyroid cancer with concomitant removal of the RLN, the lower part of the sternohyoid muscle approximately 1 cm in width and 2 cm in length with the ansa cervicalis nerve connected was inserted into the paraglottic space by way of anterior retraction of the thyroid ala with the inferior horn cut off. When the muscle or the nerve was adhesive to the cancer, the nerve-muscle on the opposite side was used with transfer through the space under the thyrohyoid muscles and the superior horn of thyroid ala. RESULTS: The voice quality was good or fair after surgery. In most patients, the maximum phonation time was 10 seconds or longer, and the mean flow rate was lower than 200 mL/s. The vocal functions were good immediately after surgery and maintained good values for 2 years or more after surgery. Vocal fold atrophy was not found in any patient. CONCLUSION: When the RLN is resected during surgery for thyroid cancer end-to-end anastomosis of the nerve is impossible, NMT to the paraglottic space is a useful method for preserving good voice and preventing atrophy of the vocal fold.

Transplantation of bone marrow stromal cells into the cochlea of chinchillas.

This study aimed to evaluate the potential of bone marrow stromal cells for treatment of inner ear diseases. Autologous marrow cells labeled with Dil were implanted into the inner ear of five gentamicin-treated chinchillas. Histological analysis 3 weeks later revealed robust survival of grafted marrow cells in multiple regions within the cochlea. Marrow cells implanted in the basal turn of the cochlea migrated as far as the apical end or into the spiral ligament of the cochlea. Some grafted cells expressed a neuronal or glial cell marker, indicating their ability to differentiate into neuronal or glial cells. Survival, migrational mobility and differentiation of autologous marrow cells in damaged cochlea suggest their potential as transplants for treatment of various degenerative inner ear diseases.

Regeneration of the vocal fold using autologous mesenchymal stem cells.

The aim of this study was to regenerate the injured vocal fold by means of selective cultured autologous mesenchymal stem cells (MSCs). Eight adult beagle dogs were used for this experiment. Selective incubation of MSCs from bone marrow was done. These MSCs were submitted to 3-dimensional incubation in 1% hydrochloric acid atelocollagen. Three-dimensional incubated MSCs were injected into the left vocal fold, and atelocollagen only was injected into the right vocal fold of the same dog as a control. Four days after injection, the posterior parts of the vocal folds were incised. The regeneration of the vocal fold was estimated by morphological and histologic evaluations. Our results showed that 3-dimensional incubated MSCs were useful in the regeneration of the injured vocal fold. This study shows that damaged tissues such as an injured vocal fold would be able to be regenerated by tissue engineering.

Recurrent laryngeal nerve regeneration by tissue engineering.

The recurrent laryngeal nerve (RLN) does not regenerate well after it has been cut, and no current surgical methods achieve functional regeneration. Here, we evaluate the functional regeneration of the RLN after reconstruction using a biodegradable nerve conduit or an autologous nerve graft. The nerve conduit was made of a polyglycolic acid (PGA) tube coated with collagen. A 10-mm gap in the resected nerve was bridged by a PGA tube in 6 adult beagle dogs (group 1) and by an autologous nerve graft in 3 dogs (group 2). Fiberscopic observation revealed functional regeneration of the RLN in 4 of the 6 dogs in group 1. No regeneration of the RLN was observed in any dog in group 2. We also tested for axonal transport, and measured the compound muscle action potential. The RLN can be functionally regenerated with a PGA tube, which may act as a scaffold for the growth of regenerating axons.

Association of chromium exposure with multiple primary cancers in the nasal cavity.

A 56-year-old man who had worked at a chromate factory for 13 years developed squamous cell carcinoma of the left nasal cavity 11 years after retirement. He received intra-arterial chemotherapy, followed by surgery. Two years later, an adenocarcinoma was identified in the same nasal cavity just above the previous surgical region. He underwent medial maxillectomy in combination with postoperative irradiation. He has been disease free for 5 years after the second surgery. Microsatellite markers were examined in the second tumor specimen as a possible factor for carcinogenesis; however, replication errors were not observed in any of four loci (D2S123, D3S1067, TP53, D18S474) tested. The present case seems to have resulted from long-term exposure to chromium and, to our knowledge, is the first reported case with multiple primary cancers in the nasal cavity associated with chromium exposure.