Exploring the relationship between plasma substance P and glottal incompetence in the elderly.

We speculated that increased blood-plasma levels of Substance P may serve as an indicator of glottal incompetence, which is usually indicated by reduced maximum phonation time. We performed an initial study to test the plausibility of this hypothesis. Patients with dysphonia caused by glottal incompetence were asked to perform vocal exercises for six months to reduce glottal incompetence and we compared the plasma concentration of Substance P before and after the vocal exercise to detect correlation between maximum phonation time and plasma concentration of Substance P. Based on the results, we further hypothesized that patients exhibiting dysphonia with maximum phonation time less than 14 s, in particular less than 10 sec, caused by glottal incompetence may have increased plasma concentration of Substance P with the results of elevated thresholds of cough reflex associated with subclinical aspiration in airways. Further study is needed on patients with decreased Substance P levels, with low scores on Activities of Daily Living and who are hospitalized with aspiration pneumonia.

Characteristics of aspiration pneumonia patients in acute care hospitals: A multicenter, retrospective survey in Northern Japan.

BACKGROUND: Pneumonia is a common cause of illness and death of the elderly in Japan. Its prevalence is escalating globally with the aging of population. To describe the latest trends in pneumonia hospitalizations, especially aspiration pneumonia (AP) cases, we assessed the clinical records of pneumonia patients admitted to core acute care hospitals in Miyagi prefecture, Japan. METHODS: A retrospective multi-institutional joint research was conducted for hospitalized pneumonia patients aged ≥20 years from January 2019 to December 2019. Clinical data of patients were collected from the medical records of eight acute care hospitals. RESULTS: Out of the 1,800 patients included in this study, 79% of the hospitalized pneumonia patients were aged above 70 years. The most common age group was in the 80s. The ratio of AP to total pneumonia cases increased with age, and 692 out of 1,800 patients had AP. In univariate analysis, these patients had significantly older ages, lower body mass index (BMI), a lower ratio of normal diet intake and homestay before hospitalization, along with more AP recurrences and comorbidities. During hospitalization, AP patients had extended fasting periods, more swallowing assessments and interventions, longer hospitalization, and higher in-hospital mortality rate than non-AP patients. A total of 7% and 2% AP patients underwent video endoscopy and video fluorography respectively. In multivariate analysis, lower BMI, lower C-reactive protein, a lower ratio of homestay before hospitalization, a higher complication rate of cerebrovascular disease, dementia, and neuromuscular disease were noted as a characteristic of AP patients. Swallowing interventions were performed for 51% of the AP patients who had been hospitalized for more than two weeks. In univariate analysis, swallowing intervention improved in-hospital mortality. Lower AP recurrence before hospitalization and a lower ratio of homestay before hospitalization were indicated as characteristics of AP patients of the swallowing intervention group from multivariate analysis. Change in dietary pattern from normal to modified diet was observed more frequently in the swallowing intervention group. CONCLUSION: AP accounts for 38.4% of all pneumonia cases in acute care hospitals in Northern Japan. The use of swallowing evaluations and interventions, which may reduce the risk of dysphagia and may associate with lowering mortality in AP patients, is still not widespread.

Metastasis of adenoid cystic carcinoma from a submandibular gland to the larynx.

The present article discusses the first reported case of adenoid cystic carcinoma (ACC) metastasis from a submandibular gland to the larynx. Both treatments of distant metastasis of ACC and secondary laryngeal tumor are challenging. Despite its slow progression, ACC is associated with high rates of local recurrence, distant metastasis, and poor prognosis. Patients with secondary laryngeal cancer often have other concurrent metastatic lesions. Therefore, treatment selection should consider the biological behavior of the tumor and characteristics of the laryngeal lesion, along with the general condition and quality of life of the patient. The patient (55-year-old female) had a history of ACC of the right submandibular gland, removed surgically 9 years prior to the present consultation. Follow-up showed multiple pulmonary metastases. The patient complained of dysphonia lasting 3 months. Following the diagnosis of ACC metastasis to the larynx (supraglottic) and a neck lymph node via biopsy, we performed partial laryngectomy, left neck dissection, and tracheotomy. Histopathological examination showed an increase in the tumor grade over time. Two months after discharge, there was no obvious local recurrence or increase in lung metastasis.

Gastric cancer metastatic to neck lipoma: a case report with imaging consideration.

A 71-year-old man visited our hospital for examination of a soft neck mass. Computed tomography and magnetic resonance imaging scans showed a well-circumscribed large lipomatous tumor with multiple nodules inside. Atypical lipomatous tumor or lipoma involving the lymph nodes was considered. Pathological examination of the surgical specimen suggested typical lipoma including multiple metastatic foci from gastric cancer. Subsequent endoscopy revealed a gastric tumor, which was histologically proven to be signet-ring cell carcinoma. Considering these findings, this case was diagnosed as tumor-to-tumor metastasis to lipoma. We present the first such case with imaging and clinical characteristics.

Carcinoma ex pleomorphic adenoma of the parotid gland: a multi-institutional retrospective analysis in the Northern Japan Head and Neck Cancer Society.

CONCLUSION: The 3-year progression-free survival rate of non-invasive salivary duct carcinoma (SDC) or adenocarcinoma not otherwise specified (NOS) was significantly better than that of invasive SDC or adenocarcinoma NOS in Carcinoma ex pleomorphic adenoma (CXPA). The presence of invasion is an important prognostic factor for SDC and adenocarcinoma NOS in CXPA. OBJECTIVES: CXPA is a rare parotid gland malignant tumor for which therapy is not yet standardized. The purpose of this study was to review the characteristics of CXPA patients and to analyze their outcomes in the Northern Japan Head and Neck Cancer Society. METHOD: The medical records of 33 patients who had been provided initial treatment in 12 institutes of northern Japan from 2002-2011 were reviewed as a multi-institutional retrospective study. RESULTS: The 3-year overall and progression-free survival rate of all patients was 79.9% and 76.8%, respectively. Both the 3-year overall and progression-free survival rates were 87.5% for patients with non-invasive SDC or adenocarcinoma NOS. The 3-year overall and progression-free survival rates for patients with invasive SDC or adenocarcinoma NOS were 60.4% and 30.5%, respectively. The progression-free survival rates for patients with invasive SDC or adenocarcinoma NOS was significantly poor (p < 0.05).

Transcanal endoscopic resection for leiomyoma of the external auditory canal and a review of the literature.

Leiomyoma usually originates from the uterus and alimentary tract, but in extremely rare cases leiomyoma can appear in the external auditory canal. Here we present a 37-year-old man with right auricular fullness. Preoperative findings suggested benign tumor or cholesteatoma in the right external auditory canal. We performed total resection using an endoauricular approach with transcanal endoscopic ear surgery. Histopathological and immunohistochemistry examination confirmed the diagnosis of leiomyoma of external auditory canal. Leiomyoma arising from soft tissue, including that in the external auditory canal, is classified into two types: that from the arrectores pilorum muscles and that from the muscle coats of blood vessels. Only four cases of leiomyoma of external auditor canal have been published in the English literature. The other four cases demonstrated vascular leiomyomas. This is the first report of leiomyoma of the EAC arising from arrectores pilorum muscles.

Extraosseous chondroma of anterior neck in pediatric patient.

Extraosseous chondroma (EC) is uncommon soft tissue tumor composed of hyaline cartilage without connection to bone or periosteum. The frequent sites of EC are the hands and feet and rarely reported in the pediatric population and anterior neck lesion. We present an extremely rare case of anterior neck mass in a 5-year-old male who underwent total resection, with the final diagnosis of EC. The review of the literature showed that all cases of EC in anterior neck lesion have been found in young age and preoperative diagnosis was difficult.

Differences between oral cancer and cancers of the pharynx and larynx on a molecular level.

In order to elucidate differences between oral cancers and cancers of the pharynx and larynx, we investigated the genetic and epigenetic changes in these tumors using molecular biology methods. Methylation of the promoter region of the p16 tumor suppressor gene was examined using methylation-specific polymerase chain reaction in specimens from 47 oral, 39 pharyngeal and 35 laryngeal squamous cell carcinomas. These specimens were also characterized for allelic loss of certain areas of the genome, i.e., 3p22, 9p21 and 17p13 (TP53). The frequency of methylation of the promoter region of the p16 gene in tongue cancers (35.3%) was significantly higher than in pharyngeal (12.8%) and laryngeal cancers (11.4%) (p=0.046 and p=0.039, respectively). The frequency of methylation in tumors of female patients (47.1%) was significantly higher compared to tumors of male patients (15.4%) (p=0.0067). In contrast, the frequency of the loss of heterozygosity (LOH) at 3p21 in pharyngeal cancers (66.7%) was significantly higher than in oral cancers (20.0%) (p=0.0006). The frequencies of LOH at 17p13 in pharyngeal (71.0%) and laryngeal cancers (73.1%) were also significantly higher than in oral cancers (36.1%) (p=0.009 and p=0.009, respectively). Our results indicate that there are marked differences in the frequencies of the hypermethylation of genes and allelic loss between oral cancers and cancer of the pharynx and larynx. Although all of these tumors were diagnosed as squamous cell carcinomas, the process of carcinogenesis may be different in tumors located in various parts of the head and neck. Loss of function of tumor suppressor genes by allelic loss gives rise to tumors in the pharynx and larynx, while loss of function due to methylation of the promoter regions of those genes is related to carcinogenesis in the oral cavity.

Distinct features of second primary malignancies in head and neck cancer patients in Japan.

Second primary malignancies (SPMs) are one of the most critical problems in treating head and neck cancer patients. Our hospital had 742 patients with a diagnosis of malignant head and neck tumors during the five-year period from 2002 to 2006. In this study, we analyzed 360 of those patients who were assumed to have risk factors such as alcohol and tobacco use: 106 oral, 120 laryngeal, 50 oropharyngeal and 84 hypopharyngeal cancer patients. Synchronous SPMs are defined as second cancers diagnosed at the same time or within 6 months of the diagnosis of the index head and neck cancers. There were 4 (3.8%) and 11 (10.4%) oral cancer patients, 11 (8.3%) and 8 (5.8%) laryngeal cancer patients, 7 (14.0%) and 4 (8.0%) oropharyngeal cancer patients, and 30 (28.6%) and 7 (8.3%) hypopharyngeal cancer patients with synchronous and metachronous SPMs, respectively. The number of metachronous patients with synchronous SPMs tended to increase during this time period. The frequencies of SPMs in oropharyngeal and hypopharyngeal cancer patients are similar to those in oral and laryngeal cancer patients. Notably, the most frequent SPMs are upper gastrointestinal tract cancers in Japan, compared to lung cancers in Europe. The five-year overall survival rate of patients with synchronous SPMs was significantly poorer than that of patients without any other tumor except for the index cancer, according to the Kaplan-Meier analysis. In conclusion, searching for SPMs in the upper gastrointestinal tract is a critical issue in head and neck cancer patients in Japan.

Melanoma-associated retinopathy associated with intranasal melanoma.

PURPOSE: To present a case of melanoma-associated retinopathy (MAR) associated with an intranasal melanoma. CASE REPORT: A 77-year-old Japanese man visited us complaining of night blindness, blurred vision, and color vision difficulties in both eyes. His best-corrected visual acuity was 0.7 in the right and 1.0 in the left eyes. The rod response of the electroretinogram (ERG) was abolished, and the maximum response had a negative waveform. The a-wave of the single-flash cone response was square shaped, and the b-wave was delayed. The ON-response of the long-flash cone ERG was absent, but the OFF-response was preserved. A severe loss of retinal sensitivity was detected by static perimetry. Positron emission tomography showed no abnormal signs. Six months after the initial examination, an intranasal tumor was detected and surgically removed. The final diagnosis based on histopathology was malignant melanoma. CONCLUSION: Our case demonstrates that MAR can be associated with an intranasal mucosal melanoma. Thus, in cases where the primary lesion cannot be identified in patients with MAR-like symptoms and signs, we recommend that preferential sites of mucosal melanomas be examined.

Introduction of new laryngeal closure methods for patients with intractable aspiration.

The aging population in Japan has recently resulted in a rapid increase in elderly individuals. Airway management is thus being required more and more often. Aspiration pneumonia is a life-threatening problem among patients with swallowing problems. Several new surgical methods of laryngeal closure that are easier and safer than previous methods have been developed. Among these new methods, we have performed the Kano method as closure of the larynx using double flaps of the divided craniad vocal folds and the divided caudad vocal folds with partial resection of the thyroid and cricoid cartilages for patients with intractable aspiration. We encountered minor leakage in two patients, but these soon closed spontaneously. This procedure is less invasive than other methods such as total laryngectomy and tracheal separation and has great advantages in terms of low blood loss and short duration of the operation.

An analysis of clinical risk factors of deep neck infection.

OBJECTIVES: To clarify the clinical risk factors that aggravate deep neck infection. PATIENTS AND METHODS: Sixty-five patients with deep neck infection (abscess or cellulitis), 42 males and 23 females, who were treated at the ear, nose, and throat department in Iwaki Kyoritsu General Hospital in the past 10 years, were retrospectively reviewed. Cases of inflammation of the upper airway including the oral cavity, laryngopharynx, palate tonsil and salivary gland, and cases of lymphadenitis were investigated. These patients were divided into five localized types and one wide range type according to the abscess locations as follows: oral cavity floor type, upper deep cervical type, submandibular type, submental type, retropharyngeal type, and wide range type. RESULTS: Seventeen of the 65 patients had diabetes, and significantly more diabetics had the wide range type than the localized type (P<0.05, Fisher's test). Diabetes complication was more often seen in the upper deep cervical type among patients aged 61 years or older, and in the wide range type among males aged 41 years or older and elderly women aged 61 years or older. No patients with odontogenic infection or sialolithiasis had associated diabetes mellitus. Two cases developed mediastinitis, and one was caused by retrotonsillar abscess and needed thoracic drainage. More than half of the wide range type cases and more than a quarter of each of the localized type cases except the upper deep cervical type also had laryngeal edema, and eight of them needed emergency tracheotomy. Thirteen of the 40 cases had bacteria belonging to the Streptococcus milleri group (SMG), and all were detected in patients who underwent surgical drainage. Four of the 13 cases where SMG was detected showed drug resistance to some sorts of antibiotics. CONCLUSION: Oral disorders can develop deep neck infection independently of the presence of diabetes mellitus, compared with other causes. The presence of diabetes mellitus is associated with deep neck infection, aggravating parotitis and wide spread of inflammation. Retrotonsillar abscess often spreads to the retropharyngeal and parapharyngeal spaces, causing mediastinitis, so caution is necessary. Infection due to SMG tends to form abscess independently of diabetes mellitus. Since more than half of the wide range type and more than a quarter of each of the localized types except the upper deep cervical type were associated with laryngeal edema, airway management should be considered.

Surgical treatment is recommended for advanced oral squamous cell carcinoma.

Oral squamous cell carcinoma is one of the most frequent types of head and neck cancers in Japan. Although recent reports have shown positive results of non-surgical treatment for advanced head and neck squamous cell carcinoma, including tongue cancer, no clear treatment strategies have been established for oral cancers, except for tongue cancer. To assess appropriate therapies, we conducted a retrospective chart review of 114 Japanese patients with oral cancers that were pathologically diagnosed as squamous cell carcinoma, excluding tongue cancers. The overall and the disease specific 5-year survival rates were 53% and 61%, respectively. Univariate and multivariate analyses revealed a lower stage (I, II, or III) and non-surgical treatment as good and poor prognostic factors of oral squamous cell carcinoma, respectively, based on their hazard ratios of 0.17 (95% CI 0.045-0.60, p = 0.0061) and 5.3 (95% CI 2.7-11, p < 0.0001). Furthermore, impact of surgery was well documented in the operable stage IVa cancers (p = 0.00015). The surgical treatment consisted of the wide resection of the primary tumor and the neck dissection for stage III or IV tumors. The present data also suggest that adjunctive therapy, such as post-operative radiation therapy or post-operative chemo-radiation therapy, shows no survival benefit compared to the surgery alone. We therefore recommend the surgical treatment for advanced oral squamous cell carcinoma in Japanese patients. These results would be helpful in future clinical trials, especially in non-surgical treatment studies of oral squamous cell carcinoma in Japan.

[Management of emergency vs. otorhinolaryngology department tracheobronchial foreign-body aspiration].

Foreign-body aspiration (FBA) obstructing the airways may lead to choking and cardiopulmonary arrest without immediate emergency care. We retrospectively reviewed medical records of 17 otorhinolaryngology subjects-8 men and 9 women aged 0 to 84 years-88% of whom were < 3 years old, requiring tracheobronchial FBA between January 1995 and October 2006 and of 62 emergency subjects-43 men and 19 women aged 0 to 91 years--10% of whom were < 3 yeares old 68% of whom > or = 50 years old, admitted between January 2000 and October 2006. Emergency Department personnel saw a mean of 8.9 patients per year versus the mean of 1.4 patients per year seen by Otorhinolaryngology Department personnel. Foreign bodies extracted most frequently from the 17 otorhinolaryngology patients were 9 seen for peanut injestion followed by 1 each seen for bean, screw, and false teeth injestion among other objects. Sixteen of the 17 were discharged without complications. Foreign bodies extracted from the 62 emergency patients most frequently involved food, especially rice cakes. Over half seen had already gone into cardiopulmonary arrest upon arrival and required cardiopulmonary resuscitation. Of the 62, 32 patients died, 13 were sent to another hospital after in-patient care, 9 were sent home without admission, and 7 were discharged without complications.

Nonrecurrent inferior laryngeal nerve without vascular anomaly as a genuine entity.

Inferior laryngeal nerve (ILN), which usually arises from vagus nerve, runs recurrent course and is called recurrent ILN (RILN). Intimate knowledge of normal and anatomic variants of the ILN reduces the risk of nerve injury and vocal cord paralysis in thyroid and parathyroid surgery. The nonrecurrent ILN (NRILN) is a rare nerve anomaly that is associated with a right aberrant subclavian artery. We encountered 2 patients with NRILN during thyroid surgery. Patient 1, a 57-year-old woman, had mediastinal thyroid tumor without vascular anomaly. Patient 2, a 47-year-old woman with a history of esophageal foreign body (fish bone), was suspected to have NRILN with vascular anomaly before surgery, as judged by preoperative enhanced CT. In the patient 1, we verified laryngeal mobility function of the NRILN by nerve stimulation, and confirmed the absence of RILN in usual recurrent course. The findings in the patient 1 indicate that NRILN without subclavian artery anomaly is a genuine entity. In both patients we performed thyroid surgery safely and fast by expectation and identification of NRILN by use of nerve stimulator. In conclusion, we confirm the existence of NRILN without vascular anomaly and show effectiveness of preoperative enhanced CT and valuable use of nerve stimulator for nerve preservation in the patients with NRILN.

Retropharyngeal abscess complicated with torticollis: case report and review of the literature.

Retropharyngeal abscess commonly develops among infants and small children, and is associated with the severe inflammation of the retropharyngeal lymph nodes located in the retropharyngeal space. Retropharyngeal abscess causes cervical pain, swelling, contracture of the neck, and in rare cases inflammatory torticollis, all of which result from an inflammatory process that irritates the cervical muscles, nerves or vertebrae. Here we report a rare case of retropharyngeal abscess with a complication of torticollis. A 4-year-old girl suffered from severe retropharyngeal abscess spreading through the deep cervical fascia, as judged by magnetic resonance imaging of the neck. Blood analysis showed high degree of inflammatory reactions, and so the patient was transferred to our hospital ward. The inflammation caused spasms of the prevertebral muscles, eventually leading to torticollis. The surgical drainage was performed immediately under general anesthesia, and an anti-inflammation therapy with intravenously administered meropenem trihydrate and clindamycin was used together with traction therapy to relieve the symptoms of the patient. We must be careful about the existence of epidural abscess and infectious spondylitis when the retropharyngeal abscess causes torticollis. In conclusion, an anti-inflammation therapy using antibiotics, along with traction therapy, was effective to relieve the symptoms. In addition to repeated clinical examinations, cooperation with orthopedists and careful follow-up are necessary. We also discussed the relationship between acute torticollis and retropharyngeal abscess.

[Management of cervical tuberculous lymphadenitis: evaluation of 6 cases].

Unlike other advanced nations, secondary spread of tuberculosis still occurs in Japan. Cervical tuberculous lymphadenitis is still an important disease of the neck, and between 2001 to 2005, we treated 6 patients with cervical tuberculous lymphadenitis. All 6 patients were females, and their ages ranged from 28 to 77 years old (average: 62 years). One patient had received antitubercular chemotherapy for pulmonary tuberculosis 40 years earlier. Two patients had a family history of pulmonary tuberculosis. One patient was an immigrant from Thailand. Three patients underwent open biopsy of the cervical lymph node, and were diagnosed with tuberculosis histologically. The remaining three patients had an abscess, and fine-needle aspiration (FNA) biopsy was performed. The diagnosis of tuberculosis was made by detection of acid-fast bacilli, MTD (Mycobacterium tuberculosis direct test), PCR (polymerase chain reaction), and culture. All six patients were treated with antitubercular chemotherapy for 6-9 months and recovered. MTD and PCR of the FNA sample seemed to enable early treatment. Attention needs to be paid to countries around Japan where tuberculosis is spreading. We suggest that treatment should be performed while at the same time making an effort to grasp the trend of spread in other countries as well as Japan.

Combined therapy after superselective arterial cisplatin infusion to treat maxillary squamous cell carcinoma.

OBJECTIVE: We sought to assess the efficacy of combined therapy after superselective arterial cisplatin infusion (SACI) therapy to treat the maxillary squamous cell carcinoma. STUDY DESIGN: We conducted a retrospective chart review of 50 patients. After completion of two courses of SACI, 25 of the patients were successively treated by concurrent SACI and radiotherapy (AR), while the other 25 patients were treated by surgery with postoperative radiotherapy (ASR). RESULTS: Patients with surgery (ASR) had an 88% local control rate with 75% disease-free survival rate at 60 months by Kaplan-Meier analysis, compared with 62% disease-free survival rate for patients with AR treatment. A particularly good outcome was obtained in T4 cases of the ASR group (n=8) whose 5-year survival rate was 87% and local control rate was 100%. CONCLUSION/SIGNIFICANCE: Combined SACI therapy is very effective for the treatment of maxillary squamous cell carcinomas and contributes to the improving prognoses of patients and organ preservation rates.

Management of the patients with hypopharyngeal cancer: eight-year experience of Miyagi Cancer Center in Japan.

The aim of this study is to evaluate the results of treatment for hypopharyngeal cancer and indicate the future prospect of the treatment. Seventy-four patients with squamous cell carcinoma of the hypopharynx admitted to Miyagi Cancer Center from 1993 through 2000 are reviewed. Sixty-four patients received radical treatment, and 10 patients received palliative treatment or no treatment. The cancer was advanced (stages III and IV) in 82% of all the patients. The overall 5-year survival rate of all the patients was 38%. The overall 5-year survival rate of 64 patients received radical treatment was 43%. The ten patients who received palliative treatment or no treatment died of cancer within 16 months. Fifty-two out of the 74 patients underwent neck dissection for the neck lymph node involvement; forty of the 52 patients underwent ipsilateral neck dissection and 12 underwent bilateral neck dissection. Four out of the 40 patients, who underwent ipsilateral neck dissection alone, developed late contralateral regional recurrence but were successfully treated by contralateral neck dissection at the time of recurrence. Twenty-three out of 74 patients had multiple primary cancers synchronously or metachronously (31%). Cause of the death of six patients out of 74 patients was confirmed to be primary cancers other than hypopharyngeal cancer, as judged by physicians in other department or other hospitals. Most of the patients died due to distant metastasis from hypopharyngeal cancer or other primary cancers. We therefore conclude that contralateral elective neck dissection which is frequently chosen for the treatment of hypopharyngeal cancer surgery is unnecessary. Even if locoregional control is accomplished, distant metastasis or multiple primary cancers emerge and make prognosis poor. To improve the prognosis, we should develop some strategy against hypopharyngeal cancer for each patient. New strategies including chemoprevention and surgery against distant metasistasis are necessary.