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Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu disease) is a systemic disorder of blood vessels. The most common manifestation of HHT is recurrent epistaxis, occurring in almost 90% of patients. Management of epistaxis is usually difficult and many types of treatment have been advocated. Of all these treatments, intranasal dermoplasty is considered the most effective one. It reduces the frequency of epistaxis by removing the telangiectasic mucosa and replacing it with a split thickness skin graft.We report a 55-year-old woman with HHT and recurrent epistaxis who was treated with intranasal dermoplasty. Postoperatively, she has shown considerable reduction in the frequency and severity of her epistaxis.

1997年4月から2004年3月までに当科において手術を施行した頭蓋底進展の悪性腫瘍症例は14例である（前・中頭蓋底8例，側頭骨4例，頸椎～斜台2例）。このうちen-bloc切除を行なえた症例は11例であった。手術時間および出血量は側頭骨手術が前・中頭蓋底の約2倍であった。局所再発は不完全切除例3例で認められ，完全切除例では局所の再発はなかった。死亡例3例中2例は遠隔転移ないしリンパ節転移再発による原病死で，1例は術後ARDSによる呼吸不全で死亡した。合併症は前・中頭蓋底ではなかったが側頭骨症例で全例が皮下髄液漏，2例で髄膜炎を認め，1例がARDSにより死亡した。手術成績の向上のためには，術前に転移の有無を見極めることと完全切除が極めて重要であり，側頭骨手術の術式の洗練と術後管理の徹底が必要である。

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.

Aneurysms of the superficial temporal artery are infrequent, and most of them are traumatic aneurysms located on the superior temporal line. We present a rare case of preauricular aneurysm of the superficial temporal artery. The patient was an 81-year-old woman who had a pulsating mass in the preauricular lesion. It was successfully removed by surgery. Histopathologically, it was suggested to be an aneurysm of the superficial temporal artery caused by atypical arteritis. She has not had active inflammatory findings, but follow-up is needed.

音声外科手術はデイ・サージャリーの良い適応である.平成8年から5年間に, 西神戸医療センターで行った局所麻酔下の喉頭内視鏡手術260例のうち, 225例 (87%) で手術を完遂できた.声帯ポリープ40例では術後の発声機能は改善し良好な成績であった.京都大学病院では平成12年にデイ・サージャリー診療部が設置され, クリニカルパスを作成して運用している.術前, 術後に患者インタビューをし, リスク, 手術の受け入れ, 心配事の表現, 声の制限が可能か, などを評価する.術後, 音声改善が不十分な場合は薬物治療や音声治療を行う.音声外科手術は比較的低侵襲だが, 合併症に局所麻酔でリドカイン中毒, 全身麻酔で喉頭痙攣などがあり, 詳細な手術の説明と記録により医事紛争の予防を図る.音声外科的治療プログラムの構築には, 耳鼻咽喉科医のリーダーシップにより, 麻酔科医, 言語聴覚士, 看護師などを含めたチーム医療が重要である.

A 50-year-old male had severe tracheal stenosis by a mediastinal goiter. The narrowest trachea part was 2mm in diameter. Therefore we scheduled the use of percutaneous cardiopulmonary support (PCPS) during tracheal intubation. By this method, we could perform tracheal intubation safely and lt-hemithyroidectomy. PCPS is a useful technique for managing severe tracheal stenosis before maintenance of the airway.

患側の声門上部を広範に合併切除する咽喉頭部分切除において, 有茎の骨筋弁と遊離前腕皮弁で声門上部と下咽頭を再建する手術を考案した。胸骨舌骨筋を茎とした舌骨半部で喉頭蓋の部分欠損を再建するとともにその有茎筋弁で披裂部の隆起を形成した後に, 前腕皮弁を用いて声門上部を被覆し下咽頭腔を再建するという方法である。これまでに下咽頭癌5例に行い, 術後の喉頭機能を評価した。全例が気切口を閉鎖でき音声が温存された。5例中4例はほぼ正常な声であった。嚥下機能は2例がほぼ正常, 2例が軽度障害, 1例が高度障害であり, 両側頸部郭清や下咽頭腔の全周切除を要さず, 術前に通過障害がないT2梨状陥凹癌例が良好な嚥下機能を示した。以上より, 咽喉頭部分切除における声門上部再建術は喉頭機能を温存するのに有用な手術方法であると考えられた。

最近4年間に6例の声門癌に喉頭部分切除を行い局所制御と術後機能を検討した。T2の2例では前側方切除を行い折畳み皮弁で声門を再建した。術後の音声機能は良好で再発もない。放射線照射後に再発したrT2の2例で前側方切除術を行い, いずれも再発はない。1例は局所皮弁で再建したが壊死を生じ顕著な嗄声が残った。他の1例は血管柄付き甲状腺で声門を再建し比較的良好な音声が得られた。T3癌の2例中1例に前側方切除を行ったが局所再発し原病死した。他の1例には披裂部と輪状軟骨を含めた拡大切除を行い欠損部を甲状軟骨片と舌骨で硬的に再建した。術後, 嗄声が残ったが呼吸・嚥下障害はなく, 腫瘍の再発もない。T2声門癌の声門再建には折畳み皮弁がよいが, 高線量の放射線照射例には血行のよい血管柄付き甲状腺が安全である。T3声門癌には拡大切除が必要で欠損部は硬的に再建するのががよいと考えられた。

我々は口腔咽頭癌切除後の欠損部の再建に皮膚成分のない胸鎖乳突筋弁を使用した5例を経験した。その内訳は口腔底癌初回例3例, 口腔底癌再発1例, 舌癌咽頭再発1例であった。全例, 頸部郭清術を施行したが, 重篤な感染は認められず, 軽度の局所感染を認めた2例も保存的治療で治癒した。長期経過観察した4例中, 1例で反対側のリンパ節に再発したが, 再手術後はコントロールされている。術後照射している症例はあるものの原発巣・あるいは患側のリンパ節の再発はなく原発巣の切除や郭清範囲に問題はなかったまた術後の嚥下障害や構音障害はなく胸鎖乳突筋弁による再建が限られているが, 症例を選べば簡便で有用な再建法である。

甲状腺癌摘出手術において反回神経合併切除後の嗄声を予防する目的で切除側の喉頭内に神経筋を移植する手術を8例に行った。切除側の甲状軟骨下角を切離して甲状軟骨板を飜転・挙上し, 約1×2cm大の胸骨舌骨筋を頸神経罠が付いたまま甲状披裂筋の外方に挿入し縫合・固定した。高齢男性の1例に喉頭浮腫が生じた。術直後から移植側の声帯は傍正中から正中に位置し声帯萎縮なく良好な音声が維持された。最長16ケ月の観察で, 声帯萎縮が生じた例や音声や音声機能が明らかに悪化した例はなかった。本手術は, 反回神経合併切除時の嗄声を予防するのに有用であると考えられた。

Thirty patients with primary hyperparathyroidism (PHPT), who were all surgically treated with a parathyroidectomy, were retrospectively studied. Ultrasonography was the most useful preoperative imaging. Pathological findings revealed 28 adenomas, 1 hyperplasia, and 1 carcinoma. In all cases, only one swollen gland was removed, and values of serum calcium and parathyroid hormone were normalized after surgical treatment. There were no significant postoperative problems. The suggested treatment for PHPT is the extirpation of one swollen gland, which is detected with preoperative imagings.

喉頭の声門上部を合併切除する梨状陥凹癌の下咽頭部分切除において誤嚥を防止する手術法を考案した。患側の喉頭蓋と披裂部を切除後，舌骨半部を胸骨舌骨筋が付着したまま甲状軟骨と喉頭蓋軟骨に固定し喉頭蓋を再建する。胸骨舌骨筋を健側の披裂部断端に縫合して披裂部の隆起を形成する。遊離前腕皮弁を用いて，再建した声門上部を被覆し，梨状陥凹を再建する。本手術を梨状陥凹癌T2N0例に行った。術後3週目に気切口を閉鎖し経口摂食を開始した。術後，音声は正常であった。呼吸機能も嚥下機能も良好で，呼吸困難や誤嚥は生じなかった。

After a partial laryngectomy on patients with laryngeal cancer with unilateral vocal cord fixation, we reconstructed the widely removed arytenoid region with a part of the thyroid cartilage or the hyoid bone. To maintain the sufficient blood flow, the sternothyroid and thyropharyngeal muscles were conserved when the thyroid cartilage was utilized. The sternothyroid muscle was preserved when the hyoid bone was utilized. The cartilage or bone was directly and firmly fixed to the cricoid cartilage. The inside of the cartilage or bone was covered with a local skin flap from the anterior neck.In two patients, the lateral half of the thyroid ala on the affected side was used in reconstructing the arytenoid. In one patient, the half of the hyoid bone on the unaffected side was used. The supraglottic tissue including the epiglottis was simultaneously removed in two of the three patients. After surgery, the functions of phonation, respiration and swallowing were conserved satisfactorily without recurrence of the cancer in all three patients.

IMTs belong to the group of soft tissue tumor and could occur at any anatomical site; however, the causes and growth feature remain unclear. This case report documents a 10-yr-old male suffering from slowly developing dyspnea on exertion and cough around seven months post-HCT. He was diagnosed with an endobronchial tumor based on imaging, and histology confirmed ALK-positive submucosal spindle-shaped cells with infiltrative cells, compatible with IMT. We should be aware that IMT is a potential complication of pediatric allogeneic HCT and can cause sudden airway obstruction.

片側反回神経麻痺症例で甲状軟骨形成術1型の適応症例は発声時の声門閉鎖不全の程度が中等度以下の症例とされている.I型の適応を拡大するために術式に改変を加えた.声門後部の間隙に対応するため, 甲状軟骨の開窓部位を約3mm後方へずらした.さらに声門閉鎖不全の程度に応じて, 大きいシリコンブロックをいれるための内軟骨膜の処理法を検討した.内軟骨膜を切開すると麻痺声帯は十分に内転するが, やや硬い感じの声になった.内軟骨膜を甲状軟骨後縁まで剥離する方法では結果は良好であるが, 手術侵襲がやや大きい.開窓部の周囲の内軟骨膜を十分に剥離することで, 大部分の症例に対応できるが, 声門間隙の極端に大きい例には披裂軟骨内転術も必要である.

We reported two cases of a bridge-like adhesion, with no history of laryngeal instrumentation, at the center of the membranous portion of the vocal fold. Such bridge-like adhesions confined to the center of the membranous portion of the vocal folds as reported in the article, are very rare. Only one other case of central vocal fold adhesion, with no history of laryngeal instrumentation, has been reported to date. The cause of the adhesion in our two cases was unknown. A simple surgical separation of each adhesion was performed successfuly with endolaryngeal microsurgery. Reccurence of the adhesion did not occur.

We developed a new method of reconstruction using a free jejunal flap after nearly total hypopharyngectomy with conservation of a functioning larynx. The free jejunum was transsected longitudinally to suppress peristalsis, and then sutured back in place. To avoid compression of the reconstructed tract by the larynx, the free jejunum was connected to one side of the pharynx after resecting the lateral half of the lamina of the thyroid cartilage. The arytenoid cartilage was fixed to the cricoid cartilage in median position after extirpation of the posterior cricoarytenoid muscle and the muscular process of the arytenoid cartilage on the affected side.The surgery described above was performed for a patient with T2 carcinoma of the piriform sinus invading the anterior and posterior walls of the post-croicoid region. Bilateral radical neck dissection was combined with this surgery. The tracheal stoma was closed three months after surgery, with no disturbance in phonation, respiration or swallowing.

2000年から06年までに京都大学病院で初治療を行ったT1，T2の下咽頭癌28例について予後と再発，合併症を調査した。放射線治療が13例に，喉頭保存手術が11例に，咽喉頭全摘頸部食道切除術が4例に行われた。原発巣再発が放射線治療の1例に生じた。永続的で顕著な喉頭浮腫が放射線治療の1例に，重篤な嚥下障害が放射線治療と喉頭保存手術のそれぞれ1例，計2例に合併した。3・5年疾患特異的生存率は96%，粗生存率は76%であった。原病死の1例は頸部リンパ節転移死，他病死の5例中3例は他癌死であった。下咽頭癌T1，T2の機能温存治療として，放射線治療と喉頭保存手術のいずれもが満足すべき結果を示した。問題点は放射線治療後の遅発性合併症と原発巣再発，進行病期例治療後の高度な嚥下障害，局所リンパ節転移と他癌の制御であった。

Two patients with inflammatory stenosis of the subglottic larynx and upper trachea due to high tracheostomies underwent an open treated reconstruction. Stenosis was observed at the level of the cricoid cartilage in one case, and at the cricoid cartilage and upper trachea in the other case. In both cases, a partial defect of the cricoid cartilage was observed on a preoperative CT scan of the larynx.Both patients were successfully treated using the “trough” method. In the initial stage, we created a trough after resection of the stenotic region through the laryngotracheal fissure. A stent formed from a silicon dental impression was inserted into the trough to maintain the wide patency of the laryngotracheal lumen. The trough was closed with a hinge flap internally and with an advancement rotation flap externally in one of the patients six months after the initial operation. In the other patient, the trough was closed with a sternohyoid myocutaneous flap internally and given an advancement flap externally four months after the initial operation.

We reviewed 14 cases of tracheobronchial foreign bodies in infants treated between 1982 and 1996 at the Osaka Red-Cross Hospital. In all cases, the foreign bodies were successfully removed using a ventilation bronchoscope under general anesthesia. The most common foreign body was a peanut, as noted in other reports. Chest X-ray findings suggested hype lucency in 7 cases, pneumonia in 2 and mediastinal shift in 2, while there were no remarkable changes found in 3 cases. Major signs and symptoms were dyspnea, wheezing and coughs in 13 cases, fever in 10 and cyanosis in 7. Preoperative administration of steroids was effective in facilitating removal of a lonstanding foreign body. We suggest that steroids should be preoperatively administered to patients who have retained a foreign body for a long period.

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 new method for the reconstruction of the arytenoid region and the vocal fold after subtotal laryngectomy was developed. The lateral half of the thyroid ala on the affected side was conserved with the thyropharyngeal and sternothyroid muscles attached. The superior and inferior horns were resected, and the thyroid cartilage was directly and firmly fixed to the cricoid cartilage. A local skin flap from the anterior neck was used to cover the inside of the thyroid cartilage.This method was performed for a patient with T3 supraglottic carcinoma invading the pre-epiglottic space and the unilateral vocal fold. The superior half of the larynx including the hyoid bone, the arytenoid cartilage and the vocal fold on the affected side and the anterior third of the vocal fold on the unaffected side were resected. After surgery, the functions of phonation, respiration and swallowing were successfully conserved without a recurrence of the carcinoma.

Between 1988 and 1995, 54 patients underwent laryngeal framework surgery, to treat glottal insufficiency due to unilateral vocal cord paralysis at Osaka Red Cross Hospital. Thyroplasty type I was performed initially in 33 patients, arytenoid adduction was performed in 18 patients, and combined thyroplasty type I and arytenoid adduction was performed in 3 patients. To date, 5 patients who had poor results from their initial surgery have undergone revision laryngeal framework surgery. Three patients who initially underwent arytenoid adduction underwent revision thyroplasty type I as a secondary procedure. Patients with vocal cord atrophy initially had to undergo combined thyroplasty type I and arytenoid adduction. Two patients who initially underwent thyroplasty type I underwent revision thyroplasty type I, with placement of a larger silicon block implant. At surgery, the tissue adjacent to the previously implanted silicon block exhibited the formation of a thin fibrous capsule. The silicon block implant was easily removed and replaced with a different, largersized, silicon block implant. The results of the revision surgery were satisfactory in all five patients.

A total of 240 patients with unilateral vocal fold paralysis (UVFP) underwent transcutaneous intrafold silicone injection (TCIFSI) for the purpose of vocal rehabilitation during the period from 1983 to 1993 in the Kurume University Hospital. Their vocal function was evaluated and the effects of TCIFSI upon the vocal function were investigated. The patients with UVFP presented with an increase in airflow during phonation; a decrease in maximum phonation time and fundamental frequency (F0) range and sound pressure level (SPL) range of phonation; and an increase in pitch perturbation quotient, amplitude perturbation quotient and normalized noise energy in the voice signal. TCIFSI resulted in a decrease in airflow, an increase in phonation time and F0 and SPL range of phonation, and a decrease in pitch and amplitude perturbation and noise in the voice signal. Patient's own subjective evaluation presented with an improvement of his/her voice after TCIFSI.

We have investigated the extent and efficacy of reasonable esophagectomy and lymphadenectomy for a carcinoma at the cervicothoracic junction in 28 patients who underwent surgery between 1980 and 1992 at Kurume University Hospital. Lymph node metastasis and/or the recurrence of these cancers was found only in the neck and/or the upper mediastinum. These findings suggest that thoracotomy for the dissection of lower mediastinal nodes is not always needed. A total laryngoesophagectomy with mediastinal tracheostomy, occasionally developed tracheal necrosis and a subsequent rupture in the great cervical vessels. However, such complications do not occur after subtotal esophagectomy preserving the larynx, or after upper esophagectomy preserving the lower esophagus. Therefore, a subtotal esophagectomy or upper esophagectomy should be adopted for esophageal cancer at the cervicothoracic junction as far as practicable-not only in order to avoid the dismal complications, but also to maintain a better quality of life for the patients.

Esophageal cancer surgery was the cause of paralysis in 111 (16.7%) of 664 patients with vocal cord paralysis seen from 1981 to 1990 at Kurume University Hospital. Eighty-six patients had unilateral paralysis, whereas 25 had bilateral lesions. Of the 111, 95 (86%) had hoarseness and 59 (53%) had aspiration. The crude survival rate was 63% for 1-year, 32% for 3-year, and 22% for 5-year follow-up. The average life expectancy was short. The general condition was poor in many patients. Thirty-four of the 136 paralytic vocal cords (25%) recovered mobility. An intracordal silicone injection was done in 30 patients, and a medialization procedure was performed in 1. The vocal function was improved in the majority of cases. In 4 patients, severe aspiration persisted following intracordal injection. Of the 4, 1 had cricopharyngeal myotomy and laryngeal suspension and 2 underwent total laryngectomy. The fourth patient died of aspiration pneumonia. The results of the review of the 111 patients have led us to the following treatment policy for patients with vocal cord paralysis caused by esophageal cancer surgery. When the patient has aspiration, vocal cord medialization should be performed as early as possible. If severe aspiration persists even after the medialization procedure, some additional intervention, including cricopharyngeal myotomy, laryngeal suspension, laryngotracheal separation, or total laryngectomy, should be considered. When hoarseness is the only major problem, the prognosis of vocal cord paralysis should be determined on the basis of the state of the recurrent laryngeal nerve and, if available, electromyography findings. Vocal cord medialization is indicated for patients with a poor prognosis for paralysis, and also for those patients whose life expectancy is short.

A rare case of thrombophlebitis of the external jugular vein is reported. The patient was a 66-year-old male and complained of cervicodynia of the right side and lockjaw. Swelling and redness were observed on the right side of his neck. Despite treatment with antibiotics cervicodynia and lockjaw worsened. On C T scan, the wall of the right extra jugular vein was thickened and circulation in the vein was obstructed. Resection of the right extra jugular vein was performed and the symptoms disapeared immediately after surgery. The resected vein had a thick wall containing a thrombus. The patient has remains well any evidence of disease 6 months following treatment.

近年, 頭頸部との多重癌が, 多く報告されている。胸部食道を含む重複癌の再建法と, 食道再建の問題点について述べた。1988年より5年間に, マイクロサージャリーを用いた腸管による食道の再建を83例行った (壊死2例, 生着率97.6%)。そのうち, 胸部食道癌を含む重複癌は12例であった。さらにこのうちで, 同時性重複癌は8例であった (7例は胃管と遊離空腸の同時作成, 1例は有茎結腸に血管吻合を追加)。この8例は, 全例生着した。気管壊死による合併症の予防のため, 遊離空腸の腸管膜 (3例), 大胸筋皮弁 (1例), 有茎大網 (5例) を使用し, いずれも重大な合併症は予防できた。移植床の血管として, 頸部: 頸横動脈・外頸静脈, 胸部上部: 胸肩峰動脈・橈側皮静脈, 胸部中部: 内胸動・静脈が有用であった。また, チーム医療の重要性と, 形成外科医の役割についても述べた。

1971年から90年までの20年間に95例の中咽頭癌症例が当科で根治的に加療された。これらの5年累積生存率は42%であった。17例が最終的に原発巣の制御不能で原発巣死した。この原発巣死が死因のうちで最も多かった。初治療として17例に手術単独治療が, 19例に放射線治療が, 59例に手術と放射線の併用治療が施行された。T1例ではいずれの治療法でも最終的に原発巣は良好に制御された。T2例では, 手術単独では原発巣再発率が高く, 放射線単独では最終的な原発巣制御率がやや低かった。T3例では放射線単独治療による原発巣の制御は不良であった。以上より, T2以上の原発巣制御には手術と放射線の併用治療がよいと考えられた。