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We report the case of a 65-year-old male who presented with a 1-week history of right periorbital pain and progressive visual loss. He had a history of ulcerative colitis and was taking oral corticosteroids and mesalazine. Neurological and radiological examination demonstrated a rare case of invasive fungal rhinosinusitis that began with orbital apex syndrome. Initial endoscopic sinus surgery was performed and fungal culture identified Aspergillus fumigatus. Although antifungal treatment was started empirically before the operation, the patient had improved orbital pain but continued to have decreased right vision. Five months after the first surgical procedure, his condition deteriorated, including loss of consciousness, and a right temporal lobe abscess was found and surgically drained. Since then, the patient received antifungal treatment for 4 years without recurrence. Invasive fungal rhinosinusitis with orbital apex syndrome should be treated with long-term postoperative antifungal medication. It should be noted that even in immunosuppressive individuals such as ulcerative colitis, fungal rhinosinusitis with orbital apex syndrome may become severe.

[Background] The hypopharynx is a closed space that is difficult to observe. The modified Killian’s (MK) method was introduced to obtain wider exposure. However, this method requires keeping the head forward during the examination. Postural maintenance might be problematic. To use the MK method safely for a thorough endoscopic examination, we introduced a new body immobilization device. The aim of this study was to evaluate the effectiveness of this body immobilization device. [Methods] Twenty-five patients underwent transnasal laryngoscopy using the MK method with the immobilization device. This device consists of a board to place the chest and a shaft. We classified hypopharynx visualization using a 5-point scale, in various combinations of head torsion, Valsalva maneuver, and MK position. Furthermore, we classified the feasibility of the MK method for 54 patients. Age, BMI, and performance status were evaluated by MK position feasibility class. [Results] The MK method with the body immobilization device was completed in all patients. It was significantly associated with higher hypopharyngeal visibility score. BMI and performance status were significantly associated with MK method feasibility. There were no significant differences in hypopharynx visualization scores with versus without this device for the patients that could maintain the MK position on their own. [Conclusion] For patients with poor nutrition or poor ability to perform activities of daily living, it was difficult to maintain the MK position. Thus, this immobilization device might be useful to complete the MK method and provide accurate detection of hypopharyngeal lesions in these patients.

Background: Lenvatinib is an oral multitargeted tyrosine kinase inhibitor that has an anticancer action in patients with differentiated thyroid cancer that is refractory to radioiodine. Knowledge of the efficacy and safety of lenvatinib in patients with anaplastic thyroid cancer (ATC) is limited. Tyrosine kinase inhibitors frequently cause hypothyroidism; the incidence of hypothyroidism with lenvatinib is unclear. Objectives: We conducted a retrospective study to investigate the efficacy and safety of lenvatinib in ATC. Methods: Five patients with unresectable ATC were enrolled. Lenvatinib 24 mg once daily was administered until disease progression, unmanageable toxicity, withdrawal, or death occurred. We retrospectively analyzed objective response rate (ORR), time to progression (TTP), overall survival, and safety. Results: Three of the five patients (60%) had a partial response, and two (40%) had stable disease. ORR was 60%. Median TTP was 88 days, and overall survival was 165 days. Hypothyroidism was a common treatment-related adverse effect; four patients (80%) had hypothyroidism of any grade. These four patients had not undergone total thyroidectomy prior to lenvatinib administration, and the other patient had undergone total thyroidectomy. Treatment-related adverse effects of any grade were hypertension in 80% of patients, diarrhea in 40%, fatigue in 80%, and decreased appetite in 80%. Conclusions: Lenvatinib is an effective treatment and may improve the prognosis of unresectable ATC. Four of five patients had hypothyroidism, which may have been associated with treatment-induced injury of the thyroid gland. There were many treatment-related adverse effects, most of which were manageable by dose modification and medical therapy.

Primary squamous cell carcinoma (SCC) in the thyroid is extremely rare and has been reported in < 1% of all thyroid cancer cases. Primary SCC in the thyroid was thought to be a transitional form derived from adenocarcinomas; therefore, the majority of reported cases have focused on the conjunction with other histological adenocarcinomas. A 73-year-old male presented to our hospital with bilateral vocal fold palsy and an anterior neck mass. Ultrasound sonography revealed a bulky tumor in the thyroid and bilateral cervical lymphadenopathy. We performed fine-needle aspiration cytology from the thyroid tumor, which revealed SCC. Positron emission tomography/computed tomography showed distant metastases in the lungs, mediastinal lymph nodes, and vertebra. We diagnosed the patient as having stage IVC SCC in the thyroid and administered weekly paclitaxel. Four and a half months after treatment initiation, the tumor progression resulted in aspiration pneumonia, which proved fatal. We performed an autopsy in accordance with the patient’s wishes. Pathological findings revealed that all carcinomas in the thyroid, cervical lymph nodes, and lungs were pure SCCs. Immunohistochemical examinations for PAX8, thyroglobulin, and TTF-1 were all negative. Differentiated thyroid carcinomas have 3 major positive markers – PAX8, thyroglobulin, and TTF-1 –, and PAX8 is also sometimes positive for SCC in the thyroid. PAX8 positivity of SCC in the thyroid might, however, be associated with conjunction with other histological adenocarcinomas such as papillary or follicular thyroid carcinoma; therefore, pure SCC in the thyroid might be negative for PAX8.

Basaloid squamous cell carcinoma (BSCC) is a histologically distinctive variant of squamous cell carcinoma comprising basal cell carcinoma and squamous cell carcinoma. BSCC is aggressive and shows a poor prognosis because of frequent lymph node invasion and distant metastases. BSCC preferentially occurs in the cervix, thymus, and esophagus and is uncommonly found in the head and neck region. BSCC in the nasal cavity or paranasal sinus is particularly rare. Inverted papilloma is an uncommon, benign tumor with a propensity to be associated with malignancy; however, BSCC arising in an inverted papilloma has never been reported. Here we report a case of a 56-year-old woman with BSCC arising in an inverted papilloma in the nasal cavity.The woman was referred to our hospital for epistaxis, nasal congestion, and dysphagia. A tumor was observed to completely occupy the left nasal cavity. The biopsy specimen was histologically diagnosed as papilloma. Computed tomography demonstrated a tumor with heterogeneous contrast effect occupying the left nasal cavity; however, extra-nasal tract extension was not observed. We performed endoscopic excision of the tumor. Microscopic findings confirmed the diagnosis of BSCC arising from an inverted papilloma. No tumor recurrence has been observed for 13 months after surgery.

ObjectiveThe increase in treatment options resulted in successful treatment with multiple lines of chemotherapy for recurrent and metastatic (RM) head and neck cancer (HNC). The present study aimed to elucidate the beneficial effect of successive treatment for RM-HNC. MethodsWe included 78 patients with RM-HNC who received one or multiple lines of chemotherapy from January 2008 to December 2019. We divided the patients into three groups according to treatment period: January 2008 to November 2012 included those who underwent cancer chemotherapy only with cytotoxic agents (Tox group), December 2012 to March 2017 included those who received cytotoxic agents and cetuximab (Cet group), and March 2017 to December 2019 included those who received cytotoxic agents, cetuximab and immune checkpoint inhibitor nivolumab (Nivo group). Moreover, we compared the overall survival of the three groups. ResultsIn total, 18, 33, and 27 patients were included in the Tox, Cet, and Nivo groups, respectively. The median overall survival were 8.5 months in the Tox group, 16 months in the Cet group, and 19 months in the Nivo group, and the difference in the result was significant. ConclusionsSuccessive treatment with second and subsequent lines of chemotherapy in patients with RM-HNC improves prognosis.

[Background] Oral mucositis (OM) is a side effect of chemotherapy in head and neck cancer. Severe OM often has a large impact on quality of life. Therefore, the treatment of OM during chemotherapy is very important. It was recently reported that Hangeshashinto (TJ-14), a Japanese traditional medicine (Kampo), is effective for OM caused by fluorinated pyrimidinebased agents used in colon cancer. We investigated the efficacy of TJ-14 for OM. [Methods] We enrolled patients with head and neck cancer who were treated with induction chemotherapy between September 2014 and March 2016. In this double-blind trial, patients were randomly assigned to the TJ-14 group or placebo group. Patients were instructed to dissolve 2.5 g of TJ-14 or placebo in 100 ml of drinking water, rinse their mouths with the solution for 30 s and then spit it out. They were not allowed to eat anything for 30 minutes before or after using the mouthwash. [Results] The incidence of ≥ grade 2 OM was 37.5% (three patients) in the TJ-14 group and 50.0% (four patients) in the placebo group, with no significant difference between the two groups. The mean day of onset was 9.7 in the TJ-14 group and 6.7 in the placebo group. The mean duration of ≥ grade 2 OM was 1.3 days in the TJ-14 group and 3.7 days in the placebo group. Thus TJ-14 significantly reduced the duration of ≥ grade 2 OM. [Conclusion] Treatment of OM with TJ-14 was associated with a statistically significant reduction in the duration of ≥ grade 2 OM compared to placebo. Gargling with TJ-14 is a safe and effective method of administering the drug to patients with head and neck cancer.

Background: Ultrasonography is superior to other imaging modalities for detecting salivary gland diseases. However, there have been no reports of the results of salivary gland screening with ultrasonography. In this study, the salivary glands were also observed during thyroid ultrasonography to determine the degree of salivary gland abnormalities detected by ultrasonography. Methods: This study was conducted retrospectively using medical records. It assessed the association between the following abnormal findings detected during thyroid ultrasonography and their final diagnoses: atrophy/swelling, unclear demarcation from surrounding tissues, decreased salivary gland parenchyma echo level, heterogeneity of parenchyma, hypervascularity of salivary gland parenchyma, dilatation of the ducts, and a mass within the gland. Results: Of the 908 patients who underwent thyroid ultrasonography, salivary gland abnormalities were detected in 36 (4.0%) patients. Of the 36 patients with abnormal ultrasonographic findings, 22 underwent further examination. Of the 22 patients, 16 received definitive diagnoses of salivary gland diseases. Salivary gland disorders were considered to be absent in patients with only heterogeneity of the salivary glands observed on ultrasonography. Salivary gland disorders in all patients with further abnormal ultrasonographic findings such as atrophy/swelling, unclear boundary, or hypervascularity in addition to internal heterogeneity were confirmed by further blood examinations and imaging studies. We were able to detect autoimmune sialadenitis such as Sj ögren’s syndrome and IgG4-related sialadenitis by ultrasonography in patients without obvious symptoms. Conclusion: Salivary gland screening during thyroid ultrasonography revealed abnormal findings including Sjögren’s syndrome and IgG4-related sialadenitis in about 4% of the patients. Thus, ultrasonography may also be useful for early detection of autoimmune diseases of salivary glands.

[Background] Postoperative hearing results of type IV tympanoplasty have been shown to have poorer results than other reconstruction techniques. There are numerous reports evaluating the factors for hearing improvement. This preliminary study aimed to analyze and determine the factors that affect hearing results. [Methods] A total of 80 patients who underwent type IV tympanoplasty were evaluated to participate in this study. The medical records of the candidate patients were collected retrospectively. Fifty out of the 80 recruited patients were excluded due to the following reasons: they could not be followed-up for more than a year after the final operation, their initial surgery was not performed in our department, or they needed a revision surgery. The pre-, intra-, and postoperative factors were evaluated and analyzed using EZR software. Cases were divided into two groups according to postoperative hearing results, and each factor was analyzed univariately. The explanatory variables included in the multivariate analysis were the variables that satisfied P < 0.1 in the univariate analysis. Furthermore, all cases were divided into two groups according to the qualitative variables that showed significant difference in the multivariate analysis, and the background factors were evaluated. [Results] The results of univariate analysis showed P < 0.1 for ‘Age’ and ‘Material of external auditory canal (EAC) packing’. Multivariate analysis showed P < 0.05 for both. The comparison between the two packing material groups showed that the gauze group was more likely to have improved hearing than Spongel? group, and the ossicular chain condition of the gauze group was maintained better. [Conclusion] ‘Age’ and ‘Material of EAC packing’ were considered to be significant factors affecting the postoperative hearing results. The selection and use of packing materials that provide stability should be considered to obtain better postoperative hearing results in type IV tympanoplasty.

Cetuximab is an effective drug used to treat patients with recurrent or metastatic head and neck squamous cell carcinoma. Skin toxicities such as paronychia and skin exsiccation are common adverse events caused by cetuximab. Skin toxicities may cause significant physical and psychosocial discomfort. The goal of managing skin toxicities is to minimize the detrimental effects on quality of life and continue the treatment. In one patient, skin toxicities became severe, up to grade 2, during treatment. The pain induced by paronychia and skin exsiccation made daily life difficult. Ten days after starting Unseiin, symptoms and finger findings resolved significantly. The patient could resume daily activities. No adverse effects induced by Unseiin were observed during treatment. Unseiin was effective on paronychia and skin exsiccation in this case and may contribute to successful treatment of skin toxicities induced by cetuximab.

A 75-year-old female patient presented with a suspected recurrence of a clival chordoma. The tumor was resected using the infratemporal fossa type B and anterior petrosal approach with the help of a neurosurgeon. During cauterization of the trigeminal nerve, the patient developed cardiac arrest for approximately 10 seconds because of the trigemino-cardiac reflex (TCR). After several sternal compressions, there was return of spontaneous circulation. The operation was resumed after the circulatory dynamics stabilized. Subsequently, the surgery was completed with partial resection of the tumor without the recurrence of cardiac arrest. The pathological diagnosis was chondrosarcoma, and postoperative treatment with radiotherapy was started. Stimulation of the sensory branches of the trigeminal nerve induces TCR. There are reports of TCR developing in approximately 10% of skull base surgery cases in the absence of atropine administration. We report a rare case of TCR during the surgical procedure for the treatment of a skull base chondrosarcoma.