President s Lecture (18th WCBE President)
E-PL
Overview of computer-assisted surgery in otolaryngology head and neck
Department of Otolaryngology Head and Neck Surgery, Kansai Medical University, Osaka, Japan
Koichi Tomoda
In the 21 century, surgical environment is changing
Otolaryngology Head and Neck surgery, Bronchoe-
now by the introduction of new technology such as ro-
sophagology
botic surgery and surgical navigation etc. These techniques are aiming for safe and reliable operation, to assist the surgeon that is called the third eye and hand .
The application of navigation system to otorhinolaryngology head and neck surgery started 1993 and should
permit safer, sounder operations when attempting revision surgery on anatomically ambiguous target organs,
surgery on lesions expanding to organs with risk factors for complications, and in minimally invasive surgery.
The usage rate of surgical navigation system in otorhinolaryngology head and neck surgery was 81!
128 (63%)
in the total institutions, in which the university hospital
was 66 (81%), municipal hospital!
medical center was 15
(19%) at the time of questionnaire survey in 2011. The
number of navigation surgery cases considerably increased in the nasal surgery with 3,514 cases (87%). On
the other hand, the number of otology and head and
neck surgery were 6%. The ratio of the absolute need
was 15% in ear cases, 23% in nasal cases and drastically
increased 46% in head and neck cases. One of the application in bronchoesophageal region is to extract foreign
body migrated into the mucosa. The navigation system
are widely used not only in the field of surgery but also
in the surgical education and training. Although this
system has the potential to improve the surgeon s confidence and knowledge of patient anatomy, the overestimate its ability should be careful without any knowledge of anatomy and surgical experiences.
On the other hand, robotic technology in the surgical
field has widely spread. However, in the field of head
and neck surgery, it has been limited because of spatial
and technical limitations. The technical and optical advantages of new robotic instruments, da Vinci S system, enable us to perform robotic surgery in the field of
head and neck. Robotic thyroid surgery or transoral robotic surgery (TORS) for meso-hypopharyngeal and
midline skull base tumor have been developed and performed in the United States and Korea. However, we
hope to develop more adequate sized and handled devices for head and neck surgery.
Keywords: CSA, Navigation surgery, Robotic surgery,
351
Keynote Lecture
E-KL
Robotic surgery in head and neck; It is time to change
from mutilating to esthetic
Otorhinolaryngology-Head and Neck Surgery, Yonsei University College of Medicine, Korea1), Department of Otorhinolaryngology, Yonsei University, Korea2)
Eun-Chang Choi1), Yoon Woo Koh2)
Head and neck tumor is characterized by its diverse origin of
tissue with rarity and serious impacts of treatment on vital
function such as breathing, speaking, chewing and swallowing. Third peculiarity is surgery in this area leaves inevitable
disfiguring scar. Although cultural perception of is different
between countries, many efforts of hiding or minimizing unsighty scar on exposed area has long been made.
Trans-oral laser microsurgery for laryngeal and hypopharyngeal tumor was introduced, but this procedure has not
been popularized due to its limitation of piece-meal fashioned
resection and of laser. Recently surgical robot with 3D closeup view and robust harmonic scalpel came into the market.
Many head and neck surgeons tried this robot on resection
of oropharyngeal tumor. Trans-oral robotic surgery is widely
and rapidly propagating worldwide, but not all esthetic problem was solved yet, because neck dissection is done separately or simultaneously with classic open surgery. Nodal
metastasis is single most important adverse prognostic factor in management of head and neck squamous cell carcinoma.
We designed various approaches of neck dissection with robot. Depending on the neck levels of neck dissection, we used
modified facelift incision or retroauricular incision. For the
lower neck tumor, trans-axillary approach was suitable. And
for the comprehensive neck dissection, we designed combined trans-axillary and retroauricular approach. Finally we
could extirpate primary tumor and neck node simultaneously without any notable scar in face and neck area. We
think this type of neck dissection is technically feasible. This
approach was quite useful not only to the young head and
neck cancer patients but also to the children with benign or
congenital head and neck tumor such as thyroglossal duct
cyst, lipoma and branchial cleft cyst.
With accumulation of the cases with robot assisted head
neck surgery, we hereby suggest the concept of Esthetic
Head and Neck Surgery which will be the first step of pulling
quality of life of head and neck cancer patients upwards.
352
Special Lecture
E-SL1
E-SL2
Reconstructive trans-oral laser microsurgery
Surgery for sleep disordered breathing
Surgery!Otolaryngology, University of Alabama at Birmingham, United States
Dept. ORL, Head & Neck Surgery, University Hospital
Mannheim, Germany
Paul F. Castellanos
Karl Hoermann
Trans-Oral Laser Microsurgery (TLM), a well-known surgical rubric, is indicated for the treatment of many forms of head and neck
carcinoma. When introduced at our specialty meetings and in our
journals there was a reaction of outrage and protest against its use.
Twenty years later TLM is considered the standard of care in
many cancer centers around the world. TLM is an early example in
medicine of natural orifice surgery, or the avoiding of external incisions.
Swallowing, breathing and speaking are all normal functions that
fail from a myriad of diseases as primary or secondary consequences. Otolaryngology has a long history of minimally invasive
approaches to aerodigestive and voice disorders beginning in the
1800 s. Just as the practice of total laryngectomy was replaced by
open partial larynx resections, and open resections by TLM, so too
is the trend toward the development of trans-oral reconstructive
techniques in replacing open approaches to a variety of ENT conditions. The advantages of a truly minimally invasive surgical approach to treat many of these problems are many and begin with
technical ease and extend all the way to improved aesthetics since
no skin incisions are needed. Open laryngoplasty based on a laryngofissure, for example, risks the integrity of the larynx in a radiated
patient or a web of the anterior commissure in everyone else.
Trans-oral approaches give the surgeon a cephalad view of the larynx, which is intrinsically more oriented to the actual function of
the larynx. The author has converted almost all of his open laryngeal and pharyngeal operations to R-TLM versions with excellent
results. Trans-oral options to treat posterior glottis stenosis, obstructive dysphagia, refractory obstructive sleep apnea, chronic aspiration, and vocal cord paralysis (beyond the injection of alloplastic
material) will be presented as examples of such care. Instrumentation and the techniques of trans-oral soft tissue rearrangement will
be described in detail. Related work by other authors will also be reviewed. A challenge will be made to all laser-surgeon colleagues to
work outside of their sphere of comfort and consider the potential
that R-TLM may supplant currently accepted open surgical approaches.
{Caption for photo: Class picture of most of the USA surgeons doing TLM in 1997 along with Prof. Wolfgang Steiner (2nd row, far
left) and the author (2nd row, far right).}
Nasal continuous positive airway pressure (nCPAP) ventilation is the gold standard in the treatment of obstructive
sleep apnoea (OSA). Long-term compliance rates are about
60%.
Therefore several alternative treatment options are of special interest. Beside conservative therapies various surgical
concepts exist.
This presentation gives an overview on different surgical
treatment options. Special focus is given on minimal invasive
surgery with video presentations of the surgery of the nose,
the soft palate, anatomical corrections and functional approaches such as hypoglossal nerve stimulation.
Being able to select among a broad spectrum of interventions after proper patient selection allows sufficient treatment in many patients otherwise remaining completely untreated.
353
Special Lecture
E-SL3
E-SL4
How to manage airway stenosis?
Reconstruction of the pharyngoesophageal defect
Department of Otorhinolaryngology-Head and Neck Surgery,
Seoul National University Hospital, Seoul National University
College of Medicine, Korea
Kwang Hyun Kim
In the field of airway reconstruction over the last 100 years,
many great surgeons have wrestled with and devised several creative approaches to the challenging clinical problem
of a narrowed airway, and eventfully has resulted in a number of effective airway reconstructive procedures that have
led to the majority of patients being successfully decannulated.
The demographics, etiology, and treatment of laryngotracheal stenosis have changed substantially since the late 1800
s. Laryngotracheal stenosis has plagued its victims and frustrated otolaryngologists for over a century. Modifications to
tracheotomy technique, the discovery of antibiotics and vaccines, the rise in high-speed automobile accidents, and the
use of prolonged intubation have altered the epidemiology of
the disease. Today, prolonged intubation in premature infants is the leading cause of subglottic stenosis and tracheotomy.
In tribute to the physician scientists who dedicated their careers to its surgical development including simple bougienage, laryngotracheoplasty, laryngotracheal reconstruction,
and cricotracheal reconstruction. These methods are now reliable, tolerable, reproducible, and highly successful methods
for airway reconstruction.
In this session, the brief history of airway reconstruction
from the early efforts with dilation procedures to open techniques and the clinical experiences of our institution in airway reconstruction will be presented.
354
Otolaryngology: Head and Neck Surgery, Mayo Clinic of Arizona, United States
Richard E. Hayden
This presentation uses clinical examples to trace the evolution of surgical techniques used to reconstruct partial and total defects of the pharyngoesophagus. Special emphasis is
placed on those defects following total laryngopharyngectomy with resection of the proximal esophagus. The evolution of flap techniques from local to regional and then microvascular free visceral and cutaneous transfer is covered.
Recent de-evolution back to new regional flaps is illustrated.
The new stenotic defects of the pharyngoesophagus created
by chemoradiation are covered together with rendezvous
procedures to ameliorate their attendant swallowing problems. In each case, clinical examples are used to compare and
contrast the benefits of each technique.
Special Lecture
E-SL5
Hypopharyngeal cancer (partial cervical esophagectomy), focusing to function preservation surgery
Department of Otolaryngology-Head & Neck Surgery, The
Catholic University of Korea, Korea, Republic of (South Korea)
Min Sik Kim
Hypopharyngeal malignancy comprised 4.3% of all head and
neck cancers and almost 80% of cancers are advanced stage
when they are discovered. The survival data are noteworthy
in hypopharyngeal cancers that the worst 5-year survival
compared with any other primary site in the head and neck,
about 30%. Usually locally advanced cancer needs to take a
aggressive treatment such as total laryngopharynectomy followed by chemo-radiation therapy. Especially hypopharyngeal cancer is an aggressive cancer that is generally diagnosed at advanced stages and consequently has a poor prognosis and a low survival rate.
Nowadays the goal of the treatment of these tumors is to
cure the patient of the cancer and to preserve or restore useful laryngeal and hypopharyngeal function. However, the
need for extensive ablative surgery often coupled with radiotherapy renders many patients incapable of performing the
basic human functions of swallowing and speech. Loss of
such integral functions has a dramatically negative effect on
a patient s quality of life, which is already threatened by the
aggressive nature of this disease. Therefore, it is imperative
to use a reliable reconstructive strategy with low morbidity
that will allow the expedient restoration of speech and swallowing.
Hypopharyngeal reconstruction remains a challenge for the
head and neck surgeon. The most challenging problem in all
partial laryngopharyngectomies is glottic insufficiency resulting from partial or subtotal removal of the laryngeal
sphincter. Conservation surgery is rarely considered suitable
in locally advanced hypopharyngeal cancer for either oncologic reasons or patient factors, such as inadequate pulmonary reserve and postoperative swallowing disorders. And
chemo-radiotherapy takes the role of replacing surgery for
the purpose of organ preservation.
Recently surgical procedures to solve these problems is developed to this stubborn enemy. Vertical partial laryngopharyngectomy and other partial technique could be an answer
for the surgeons for the successful treatment of locally advanced hypopharyngeal cancer. We can revise and introduce
the surgical procedures for locally advanced hypopharyngeal cancer with satisfactory oncologic and functional results.
355
Educational Lecture
E-EL1
E-EL2
Education and training for residents and fellows for
the management of voice disorders
Transoral surgical approaches for pharyngeal
dysphagia
Department of Otorhinolaryngology-Head & Neck surgery,
Kansai Medical University, Japan
Department of Otolaryngology Head and Neck Surgery, Kurume University School of Medicine, Japan
Makoto Miyamoto, Hideyuki Murata, Koichi Tomoda
Shunichi Chitose, Kiminori Sato, Mioko Fukahori,
Shintaro Sueyoshi, Takashi Kurita, Akiteru Maeda,
Hirohito Umeno, Tadashi Nakashima
Hoarseness is a term used to describe changes in voice quality. This reflects a variety of vice disorders. Thus, we need to
examine a vocal cord findings precisely. The approach to the
patients who presents with hoarseness will be discussed, especially laryngeal flexible videoscopy and stroboscopy. Laryngeal stroboscopy is very useful to evaluate the vibratory
characteristics of the vocal fold.
The training of variety of surgery has been developed recently. Microlaryngeal surgery has been in regular use for
several decades, and the technique is well recognized as an
effective option for the treatment of voice disorders. Safe and
efficacious application of the techniques requires appropriate
training for residents and fellows. Unlike open procedures,
trainees cannot be mentored effectively during minimally invasive laryngomicrosurgery on actual patients because most
procedures are singleoperator dependent. It is important
that trainees acquire these skills outside of the operating
room. Therefore, there is a great need to produce laryngeal
simulators to practice the skills required for this surgery. We
use a surgical simulator that recreates the laryngomicrosurgery. The assessment for the learning effect was conducted
in comparative trials performed before and after the training. According to the result, this model was effective in helping understand the position of vocal cord, forceps and laryngeal endoscope.
356
Surgical approaches for improving function of swallowing
have been performed for the patients with pharyngeal
dysphagia since half a century ago. Among them, transcervical cricopharyngeal myotomy (TCPM) has sufficient potential
to improve cricopharyngeal dysphagia due to pharyngeal paralysis as well as idiopathic myopathy. Over the past decade,
endoscopic cricopharyngeal myotomy (ECPM) using a laser
has been introduced as an alternative surgical procedure to
TCPM. Further, injection laryngoplasty (IL) or pharyngeal
flap surgery (PFL) also have been adapted for dysphagia
caused by incomplete glottal closure or veropharyngeal insufficiency, respectively. We present a paradigm with transoral
procedures including ECPM.
The goals of this presentation are as follows:
First, is to introduce a new paradigm of ECPM. This surgical
procedure used for the cricopharyngeal dysphagia is a modification of conventional ECPM consisting of the following steps:
1. Postcricoid placement of a Weerda laryngoscope. 2. A vertical midline incision in the mucosa covering the cricopharyngeal muscle is made with a CO2 laser. 3. The posterior aspect
of the cricopharyngeal muscle is widely separated from the
buccopharyngeal fascia. 4. While grasping the cricopharyngeal muscle with two clamps and putting traction to it, a submucosal resection at the one side of the cricopharyngeal muscle is made with the CO2 laser. 5. Another side of the cricopharyngeal muscle is excised as widely as possible. 6. The initial mucosal incision is sutured horizontally.
Second, is to compare ECPM with TCPM about the postoperative effectiveness. In Japan, TCPM has been modified to a
wide resection of cricopharyngeal muscle. Because the
neuromuscular junctions have unequal distribution in a cricoid muscle, the amount of the junctions in the muscle excised by each method should influence the postoperative effectiveness from the standpoint of the reinnervation. In our
study based on neuromuscular theory, the wide resections of
cricopharyngeal muscle with the TCPM and the ECPM had
equal postoperative effectiveness consequently.
Third, is to indicate transoral approaches for pharyngeal
dysphagia (TAsPD). Conventional TCPM have been occasionally used in combination with laryngeal suspension for severe
pharyngeal dysphagia. However, since these transcervical approaches are invasive for the elder patients with pharyngeal
dysphagia, their postoperative morbidities can be temporarily worse than preoperative statement. In contrast, ECPM
can be transorally performed in combination with IL and!or
PFS as necessary. TAsPD is less invasive and results in
fewer complications than cervical approaches. In addition,
TAsPD can provide persistent efficiency without morbidities
progression.
And finally, to discuss applications of TAsPD.
Symposium
E-SY1-1
E-SY1-2
Transnasal esophagogastroduodenoscopy (EGD) with
NBI in diagnosis of hypopharyngeal and simultaneous
esophageal cancers
The treatment outcomes of synchronous esophageal
squamous cell carcinoma and head and neck
squamous cell carcinoma
Department of Otolaryngology, National Taiwan University
Hospital and College of Medicine, Taiwan1), Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine2)
Department of Gastroenterological Surgery, National Kyushu
Cancer Center, Japan1), Department of Head and Nech Surgery, National Kyushu Cancer Center, Japan2), Department of
Radiology, National Kyushu Cancer Center, Japan3)
Jenq-Yuh Ko1), Cheng-Ping Wang1), Pei-Ming Huang2)
Yasushi Toh1), Akinori Egashira1), Manabu Yamamoto1),
Muneyuki Masuda2), Naonobu Kunitake3),
Kazuhiro Okushima3), Takeshi Okamura1)
Hypopharyngeal cancer is the 4th common head and neck
cancer in Taiwan with late stage and poor prognosis. The
conventional diagnosis of hypopharyngeal cancer is made by
rigid laryngoscopy esophagoscopy under general anesthesia, but with difficulty in some situations. Meanwhile, the
prognosis of esophageal cancer in Taiwan is poor too because of late diagnosis. We use ultra-slim transnasal EGD
(GIF-XP260N, Olympus, Japan) from 2007 to diagnose hypopharyngeal cancer and early detect simultaneous occult
esophageal lesion. From May 2007 to October 2013, there are
234 cases of hypopharyngeal cancer proved by transnasal
EGD. The mean age is 56 years (33y-90y). The male to female
ratio is 228:6. Most cancers (85%) are in the pyriform sinus
and with stage IV (71%). Simultaneous esophageal lesions
were found in 44% of patients: invasive esophageal cancer:
(16%), dysplasia: (8%), Lugol void lesion alone: 20%. The T
classifications of the esophageal cancer are T1-2: 50%, T3-4:
20%, unknown:30%. The combination of standard endoscopy
plus NBI can yield the best sensitivity, specificity and accuracy. The survival of hypopharyngeal cancer patients improves (P<0.001) after the policy of esophageal screening. Finally, a case report will be presented.
Background
The treatment outcomes of the patients with esophageal squamous cell carcinoma (ESCC) and
head and neck squamous cell carcinoma (HNSCC) have been poorly documented. The aim of
this study is to evaluate the treatment outcomes of the patients with synchronous ESCC and
HNSCC.
Patients and methods
Sixty-two patients with synchronous ESCC and HNSCC during 2003-2012 were enrolled in this
study. We investigated the clinicopathological characteristics, the initial treatments and the
survival rates of these patients. Especially, we focused on the treatment results of 28 patients
with synchronous ESCC and HNSCC who received simultaneous definitive chemoradiotherapy (dCRT).
Results
There were 46 patients (74.2%) with stage 0-I ESCC and 36 patients (58.1%) with stage III-IV
HNSCC. Fifteen cases presented multiple cancers in the esophagus and 18 cases had experienced metachronous multiple cancers of other organs. As an initial treatment, a total of 11
(18.0%) patients underwent endoscopic mucosal resection, 13 (20.9%) underwent curative surgery and 34 (54.8%) underwent dCRT for ESCC, whereas 39 (62.9%) and 16 (25.8%) of the patients with HNSCC were treated with dCRT and curative surgery, respectively. Simultaneous
dCRT was performed for 28 (45.2%) and simultaneous curative surgery was done for 8 (12.9%)
of the patients with synchronous ESCC and HNSCC. The 5-year overall survival rates (OS) of
all 62 patients with synchronous ESCC and HNSCC was 49.9%. The planned treatment was
completed in 25 (89.3%) of 28 patients who received simultaneous dCRT (chemotherapy regimens: CDDP+5-FU in 15, platinum-based monotherapy in 12 and TS-1 in one patients). Although grade 3-4 adverse events were observed in 10 (35.7%) patients, there were no
treatment-related deaths. Complete responses (CRs) were observed in 18 (64.2%) and 11
(39.3%) of the patients with ESCC and HNSCC, respectively. One and 10 non-CR cases of ESCC
and HNSCC underwent surgery, respectively. Four (22.2%) of 18 CR cases of ESCC showed recurrences (All were Stage 0 and I, and 3 patients had received a platinum-based monotherapy
as an initial chemotherapy). The 5-year OS of these 29 patients was 47.3%.
Conclusions.
Nearly half of the patients with synchronous ESCC and HNSCC were initially treated by simultaneous dCRT and the survival rate was fair. However, the CR rate of ESCC was relatively low, although two thirds of the patients were in stage 0 or I, suggesting the optimal chemotherapy regimens of simultaneous dCRT for synchronous ESCC and HNSCC remain to be
determined.
357
Symposium
E-SY1-3
E-SY2-1
Therapeutic strategies for head and neck cancer associated with esophageal cancer
Normal and disordered pharyngeal phase of swallowing
Department of Otolaryngology-Head and Neck Surgery, Kobe
University Graduate School of Medicine, Japan
Naoki Otsuki, Hirotaka Shinomiya, Hirokazu Komatsu,
Koichi Morimoto, Miki Saito, Ken-ichi Nibu
The incidence of synchronous or metachronous multiple primary cancers has increased in patients with head and neck
cancer. In particular, esophageal cancer is frequently associated with hypopharyngeal squamous cell carcinoma. At
Kobe University Hospital, 194 patients were diagnosed with
hypopharyngeal cancer between 2007 and 2012. A total of 66
patients (34%) were associated with esophageal cancer synchronously or metachronously. Cigarette smoking and alcohol consumption are both recognized as risk factors for multiple cancers of the head and neck and the esophagus. The
early detection of second primary cancer may allow for less
invasive treatment, such as endoscopic or microscopic transoral resection and preservation of the larynx, resulting in a
more favorable outcome. We performed routine screening
and close follow-up in cooperation with gastroenterologists
for the detection of second cancers using endoscopy with Lugol s staining and narrow-band imaging combined with magnifying endoscopy. The treatment of patients with double
cancers of the head and neck and the esophagus is usually
complicated. Various factors must be considered when determining the appropriate therapeutic strategy, including
the curability and prognosis of both cancers, complications of
treatment, general status of the patient, and quality of life after treatment. In this report, the incidence, treatment and
outcome of double cancers of the pharynx and the esophagus
are reviewed, and the clinical problems related to the association of hypopharyngeal cancer with esophageal cancer
are discussed.
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Otolaryngology, University of California, Davis, USA
Maggie Kuhn
Safe and efficient deglutition depends on a precisely-timed
and highly-coordinated series of events in the pharynx. The
involuntary pharyngeal phase of swallowing begins when
the lingual palatal valve opens and allows the bolus passes
into the oropharynx. Bolus transit through the oropharynx
and hypopharynx relies on a competent velopharyngeal
valve, intact tongue base and pharyngeal constrictor
strength, adequate elevation of the hyolaryngeal complex
and relaxation of the cricopharyngeus muscle. Impairment of
any of these components results in dysphagia which may
manifest as a spectrum of problems from mild difficulty with
solid foods to profound disability with feeding-tube dependence.
Common causes of pharyngeal phase dysphagia include head
and neck cancer treatment, cerebrovascular accident,
neurodegenerative disorders, iatrogenic injury and myopathy. Evaluation begins with the clinical assessment including
detailed history, feeding behaviors and comprehensive head
and neck examination. The gold standard instrumental tool
for workup of pharyngeal phase dysphagia is the videofluoroscopic swallow study. Lateral and anterior-posterior
fluoroscopic views afford assessment of velopharyngeal competence, pharyngeal stripping wave, laryngeal elevation, airway protection and pharyngoesophageal segment opening.
Treatment for pharyngeal phase swallowing disorders is
best approached by a multidisciplinary team including physician, speech language pathologist and dietitian. Therapeutic
interventions ought to be individualized to patients based on
degree of swallowing impairment, laryngeal function, overall
health and adherence to recommendations. A number of
pharyngeal phase pathologies are amenable to surgical intervention including velopharyngeal incompetence, pharyngoesophageal segment stenosis, cricopharyngeus muscle dysfunction and intractable aspiration. The multitude of other
problems are better served with therapy, dietary modifications, behavioral interventions and occasionally alternate
means of nutrition.
Symposium
E-SY2-2
E-SY2-3
Simple and clinic-based scoring system for endoscopic swallowing evaluation and its clinical significance
Clinical applications of behavioral management strategies in cricopharyngeal dysphagia
Department of Otolaryngology, Kochi Medical School, Japan1),
Department of Otolaryngology, Takanoko Hospital, Japan2)
Masamitsu Hyodo1), Kahori Hirose1), Kaori Nishikubo2)
Dysphagia is recently becoming a critical issue medically
and socially in an aging population. Appropriate treatment
requires objective evaluation of swallowing function. We developed a simple, clinic-based scoring system for endoscopic
evaluation of swallowing. It uses four parameters; 1) degree
of salivary pooling at the vallecula and piriform sinuses, 2)
glottal closure reflex induced by touching the epiglottis or
arytenoid with the endoscope, 3) swallowing reflex initiation
assessed by white-out timing, and 4) pharyngeal clearance
after blue-dyed water swallowing. The findings were categorized as 0 for normal, 1 for mildly, 2 for moderately, or 3 for
severely impaired. Scores given by experienced otolaryngologists in treating dysphagic patients correlated significantly with those by non-experienced otolaryngologists or
speech-language-hearing therapists. Pharyngeal clearance
evaluated by videofluorography significantly correlated with
videoensoscopic clearance scores. Oral diet characteristics
showed significant relationships with total scores of the four
parameters, indicating that the scoring system can propose
diet recommendation guidelines. Consequently, this scoring
system is simple and reliable for evaluating severity and feature of dysphagia and is sufficiently worth introducing into
the clinical use.
Deartment of Otolaryngology Head and Neck Surgery, The
Catholic University of Korea, School of Medicine, Korea
Young-Hak Park
This study was designed to set a management protocol for
cricopharyngeal dysphagia caused by lower cranial nerve
deficits. Retrospective chart review of 48 patients of cricopharyngeal dysphagia by lower cranial nerve deficits was
conducted. All patients needed nasogastric tube feeding before treatment and oral feeding was achieved in 46 patients
after treatment, from 1 to 24 weeks duration, reaching 96%
of success rate. Flexible laryngoscopy, fiberoptic endoscopic
evaluation of swallowing and videofluoroscopy were used to
evaluate patients. Positional change and swallowing maneuvers were used in all patients during evaluation. Most frequently used positional change was head rotation to damaged side. Behavioral management, swallowing exercise and
electrical stimulation were used during treatment if needed.
Medialization laryngoplasties were conducted in 30 patients.
Cricopharyngeal release procedure was successful in 8 patients. After these methods, more invasive surgical procedure were conducted in 4 patients. The protocol we used
was designed to arrange treatment options from behavioral
management and medialization laryngoplasty first, and
when these methods were not enough in managing cricopharyngeal dysphagia, then more invasive methods were conducted.
359
Symposium
E-SY2-4
E-SY2-5
Dysphagia in Parkinson s disease
Indications and outcomes of cricopharyngeal
myotomy and laryngeal suspension for oral cancer surgery
School of Rehabilitation, Hyogo University of Health Sciences,
Japan
Sonoko Nozaki
Parkinson s disease (PD) is a slowly progressive neuromuscular disease, and is often seen in elderly people. Treatment approaches, pharmacologic or surgical,are dictated by the presence of specific symptoms.
In the progression of disease, both motor and nonmotor
symptom manifest. Motor symptoms include wearing off, onoff phenomenon, dyskinesia, and dystonia as a side effect of
pharmacologic treatment. Nonmotor symptoms include depression, apathy, defatigation, hallucination!
phantasm, depression disorder, cognition disorder, orthostatic hypotension, urination disorder, enterokinesis disorder, psychosexual
dysfunction, dyshidrosis, and pain. Most of these symptoms
are related to dysphagia.
Dysphagia in PD is an important prognostic determinant and
significantly reduces the quality of dietary habits in PD patients. It is present in at least half of PD patients, sometimes
from the early stages of the disease, and is not necessarily related to the Hoehn-Yahr stage. Patients have poor awareness
of dysphagia; consequently, silent aspiration is common
among them. Long-term consumption of anti-PD medication
can result in deterioration of dysphagia because of dyskinesia and the off phase of the on-off phenomenon. A variety of
disorders involving voluntary movements, reflex actions, and
autonomous movements occur across each phase of swallowing.
The malignant syndrome is a complication of drug treatment, resulting from dose reduction or sudden withdrawal of
antiparkinsonian drug, psychotropic drugs, or dehydration.
It manifests as muscle rigidity, high fever, increased creatine
kinase, diaphoresis, tachycardia, immobility, disturbance of
consciousness, and severe dysphagia. Drooling occurs as a
result of decreased salivary deglutition.
Body weight usually decreases before the onset of pharmacologic treatment, increases after initiating medication, and
decreases again in the advanced stage of disease.
Meta-analysis revealed that levodopa intake was not associated with an improvement of swallowing dysfunction in PD.
Some reports indicated that modalities such as deep brain
stimulation and surgical therapy actually worsened swallowing disorders.
Recent reports have found that the increased occurrence of
inspiratory events after swallowing and shorter swallowing
apnea may serve as important indicators of the risk of penetration!
aspiration. Expiratory muscle strength training significantly increases cough volume acceleration and decreases the risk of penetration!
aspiration.
We reported previously that rhythm treatment for
dysphagia with a metronome improves swallowing function
in patients with PD. Metronome treatment shortens oral
transit time and can be continued for a long period of time.
With appropriate management, evaluation of deglutition
function and prevention of disuse syndrome, we can maintain optimum swallowing function in patients with PD.
360
Department of Otolaryngology, Nagoya University School of
Medicine, Japan
Yasushi Fujimoto, Maruo Takashi, Mariko Shimono,
Mariko Hiramatsu, Nishio Naoki, Kenji Suga,
Yusuke Koide, Tsutomu Nakashima
Background: To prevent post surgical dysphagia in oral cancer patients who had undergone extensive resection, cricopharyngeal myotomy and laryngeal suspension is recommended; however, the criteria that determines this course
remains controversial. We opted for crico-pharyngeal
myotomy and laryngeal suspension when it was thought
that patients would lose the mechanisms to elevate the larynx or to produce oropharyngeal pressure3; subtoral
glossectomy with bilateral resection of the suprahyoid muscles, or resection more than half of tongue base. We classified
this group as high risk . On the other hand, we have not
opted for these methods when we performed subtotal
glossectomy with preservation unilateral suprahyoid muscles. We classified this group as low risk . But some patients
in low risk group could not achieve an oral diet. In 1996, we
extended the criteria for crico-pharyngeal myotomy and laryngeal suspension for elderly patients (over 60 years old) in
low risk group. We classified this group as intermediate
risk .
Patients and Methods: Since 1994, 100 patients at the Aichi
cancer center hospital and the Nagoya university hospital
underwent wide resection of the tongue followed by reconstructive surgery. Among them, thirty patients were classified in the intermediate risk group. In order to verify the
new indication, we compared postoperative swallowing function of intermediate risk group patients between 2 groups
(Group A [15cases] from June 1994 to September 1996, Group
B [15cases] from October 1996 to 2013.) by both videofluorography and oral diet. Upon determining the new criteria, Group B patients received crico-pharyngeal myotomy
and laryngeal suspension.
Results: Out of group A, 2 patients could not achieve an
oral diet, but all the patients out of group B could. In videofluorography, the amount of aspiration in group B was less
than in group A. We also noticed much residual bolus in the
pyriform sinus in some patients in group A. Conclusions: A
crico-pharyngeal myotomy and a laryngeal suspension can
contribute to the prevention of post-surgical dysphagia in
elderly patients.
Symposium
E-SY3-1
E-SY3-2
Sentinel node biopsy in larynx & oropharynx
Sentinel navigation surgery for oral cancer
Université Catholique de Louvain, Cliniques Universitaires de
Mont-Godinne, Belgium1), ORL et chirurgie cervico Medecine
Nucleaire2), Centre Hospitalier Universitaire UCL de MontGodinne. BELGIUM3), ORL et chirurgie cervico Biostatistique4)
Georges Lawson1), Van Derborght2), Th., Nollevaux MC3),
Remacle M1), Jamart J4)
Objectives:
To assessed the feasibility and reliability of performing sentinel node biopsy in larynx and oropharynx.
Methods:
Sentinel node biopsy (SNB) was performed in 2 groups of patients with Laryngeal Squamous cell carcinoma (SCC). Group
I (82 patients): SNB plus Neck dissection; Group II (68patients): SNB alone follow by neck dissection only on patient
with positive SN.
This study was a prospective human trial approved by our
institutional ethical comity.
Results:
Sentinel Node detection was 100% in both groups, with respectively 39% and 35% of positive sentinel nodes (SN). The
minimum time between radiotracer injection and SNB was
20mn in group I, and 15 minute in group II. The number of
SN per patient was 3 and Identification rate was 98% in
group I & 94% in group II. As an abnormal drainage pattern
we observe 12% of positive SN on contra lateral side and 6%
of skip metastasis.
Conclusions:
These preliminary results of our series suggest that application of SNB for laryngeal & oropharyngeal SCC is technically
feasible, reliable and safe in a context of Head and neck cancer. The SNB improved staging of clinically N0 neck by identifying micro metastases.
Department of head and neck surgery, Aichi Cancer Center,
Japan
Hitoshi Hirakawa
The proper treatment of the nodal negative neck in early (T
1!
T2) oral squamous cell carcinoma (OSCC) is remain controversial. Elective neck dissection (END) is the current gold
standard therapy in patients with nodal negative neck in
early OSCC.
END is both a staging and a therapeutic procedure, which
represents a potential benefit for patients who are subsequently found to harbor occult disease. However, these patients represent only approximately 20-30% of the population, leading to the possibility of overtreating the remaining
70-80%. Because the morbidity associated with neck dissection is considerable, alternative management of clinically
negative (cN0) neck has been discussed.
Sentinel node biopsy (SNB) potentially allows for staging of
the cervical lymph nodes without the morbidity of a neck
dissection. In addition to be an accurate means of staging the
clinically negative neck, more recently, the potential prognostic value of SNB for oral cancer has also been reported.
In our data, 5-year overall survival rate of SN-positive patient
was 57.1% and that of SN-negative patients was 96.6%. Positive SN had a negative impact on the survival (Terada, Eur
Arch Otorhinolaryngol 2011). However, the institution performing SNB is still limited and, moreover, procedure of surgical treatment and pathological analysis have some difference among the facilities. For standardization and further
spread of SNB procedure, we evaluated the efficacy and
safety of SNB with same surgical procedure and pathological
analysis in a multicenter study.
57 patients with oral cancer from ten institutes were enrolled. SN were identified in all patients in all institutions. We
could perform immediate neck dissections based on the results of intraoperative multislice frozen section analysis as a
single-stage procedure. False negative rate was 5.6% and
NPV was 94%. The 2-year overall survival rate of all patients
was 94.4%. The 2-year overall survival rate of SN-negative
and SN-positive patients were 100% and 84.0%, respectively.
This difference was deemed statistically significant (log-rank
test, P=0.02). The presence of positive SNs demonstrated
negative impact on OS.
SN navigation surgery for oral cancer is technically feasible
and possibility of the further spread of SNB was suggested.
361
Symposium
E-SY3-3
E-SY3-4
Sentinel node navigation surgery using indocyanine
green fluorescence imaging for head and neck cancer
Feasibility of novel tracers for sentinel node detection
in head and neck region
Department of Otolaryngology, Head and Neck Surgery, Kyorin University School of Medicine, Japan
Yasunao Kogashiwa, Naoyuki Kohno
The sentinel node (SN) biopsy concept has been adapted
early oral cancer during the last decades with great success.
Radioisotope (RI) method is the most widely used, however
this technique has some problems. We can t get direct visualization of the SN, it is limited to use in nuclear medicine
laboratory and radiation exposure to the patient and medical
staff. It is very hard to apply the RI method to the pharyngeal!
laryngeal cancer because pharyngeal reflex occurs under patients conscious level of awareness. Indocyanin Grenn
(ICG) fluorescence in the mapping and detection of sentinel
lymph nodes is also a promising approach for the pharyngeal!
laryngeal cancer because we can easily inject ICG during an operation. A total of five consecutive patients with
tongue or pharyngeal cancer and N0 neck status and where
resection of the primary tumor was planned were evaluated
the ICG fluorescence to identify the SN. The infrared video
camera was then directed toward the cervical area to identify the sentinel lymph node. Three cases combined with radioisotope method. Sentinel nodes biopsy positive patients
were going to receive elective neck dissection while sentinel
nodes biopsy-negative patients were omitted the neck dissection. In four cases the sentinel nodes could be identified,
however in one case we could not detect the SN percutaneously with ICG fluorescent method. In one case, sentinel
node was pathological positive. Then the neck dissection was
performed. ICG fluorescence is a potential valuable tool in
the detection of SLN in patients with head and neck cancer.
It was found that ICG methods have some problems. The
problems are that the fluorescent tracer quickly migrated
beyond the SN and we may not be able to identify the SN
through the skin in case of the patients who are too muscular
or fatty. Further investment are needed and we will introduce some experimental data to solve the problems on the
session.
362
Department of Otolaryngology-Head & Neck Surgery, National Defense Medical College, Japan1), Functional Imaging Division, Research Center for Innovative Oncology, National
Cancer Center Hospital East2), Department of Radiology, National Defense Medical College3)
Koji Araki1), Daisuke Mizokami1), Masayuki Tomifuji1),
Taku Yamashita1), Kazunobu Ohnuki2), Izumi Umeda2),
Hirofumi Fujii2), Shigeru Kosuda3), Akihiro Shiotani1)
[Objective]:
Popular sentinel node (SN) detection method using radionuclide
(RN) has some drawbacks, such as the strict legal regulations
and the shine-through phenomenon. Therefore the tracer best
suited to SN detection in head and neck region is needed.
Superparamagnetic iron oxides (SPIOs) generate a strong negative contrast in gradient echo sequences of magnetic resonance
(MR) images. Interstitial MR lymphography produced excellent
results in the detection of SNs, and is already in use for human
breast or lung cancer patients. Real-time, near-infrared (NIR)
imaging with indocyanine green (ICG) is also becoming popular
as a detection method. The major drawback of this method is
its quick migration through the lymphatics, limiting the diagnostic time window and undesirable detection of downstream
nodes.
To examine the feasibility of novel tracer in the head and neck
region, (1) MR lymphography using SPIO for SN detection in
animal and in human tongue cancer, and (2) novel ICG technique by mixing with phytate colloid to retard its migration in
animal were investigated.
[Materials and Methods]:
(1) T2＊WI images were acquired using 4.7-T MRI after SPIO
injection into the tongue of nude mice. MR images were also acquired after injecting SPIO around the tumor in three patients
with tongue cancer (clinical T2N0M0). 99mTc-phytate SPECT!
CT lymphoscintigraphy was also taken to detect the SNs.
(2) ICG or ICG-phytate colloid mixuture solution was injected
into the tongue of nude mice and NIR images were captured.
The brightness of fluorescence in SNs and downstream lymph
nodes were assessed.
[Results]:
(1) The mean numbers of lymph nodes visualized were 4.00
nodes for on SPECT!CT and 2.0 for MR lymphogram in animal
experiment. The SNs were clearly visualized in the 10 min MR
lymphography images and were completely concordant with
those visualized by 99mTc-radiocolloid lymphoscintigraphy and
a gamma probe in all human cases. Iron incorporation into the
SNs was confirmed by pathological examination.
(2) The addition of phytate colloid to ICG extended the period
when SN was detectable. Second echelon lymph nodes were
not imaged in animals injected with the mixture.
[Conclusions]:
SPIO have a potential of being employed for SN detection by interstitial MR lymphography in the head and neck region. And
novel technique of ICG-phytate colloid mixture allows improved
accuracy for the detection of SNs with NIR imaging. Our results indicate that these novel methods may have potential to
replace current RN techniques.
Symposium
E-SY4-1
Modern surgery for esophageal cancer
Surgery, The University of Hong Kong, Hong Kong
Simon Law
Surgical treatment for esophageal cancer has made great
progress in the past decades. It used to be a procedure of
high mortality rate. With improvement in surgical techniques and peri-operative care, esophagectomy has been
made relatively safe. In specialized centers, a mortality rate
of less than 5% can be achieved. Morbidity rates remain high.
The invasive surgery, especially with extended lymphadenectomy, performed on an elderly population with comorbidities, has its associated complications. Survival after
treatment has improved, especially with increasing use of
multimodality strategies.
Minimally invasive surgery in the form of video-assisted thoracoscopic ＋!
- laparoscopic esophagectomy, has become
more popular. Equivalent, or even superior lymphadenectomy can be performed compared to open surgery. Some debatable aspects of minimally invasive esophagectomy remain, including its appropriate indication, lateral position vs.
prone position, whether an intrathoracic or cervical esophageal anastomosis should be performed, and whether laparoscopic gastric mobilization should be an integral part of the
procedure in addition to thoracoscopy, and if so, should the
gastric conduit be prepared intra-corporeally or extracorporeally. In over 200 minimally invasive esophagectomy
performed at The University of Hong Kong, a mortality rate
of 1% was achieved. Equivalent lymph node harvesting and
survival was found compared to open surgery. Only one
European multicenter randomized trial has been conducted
comparing minimally invasive esophagectomy and open
transthoracic resection. Less pulmonary complications were
found. More trials are needed to truly prove its benefits.
The results of surgery will improve further. The challenge of
modern surgery is how best to individualize surgical procedures for patients with different stages of disease, comorbidities, and after neoadjuvant therapies.
363
Symposium
E-SY4-2
Minimally invasive esophageal surgery in the view of quality of life
Department of Thoracic and Cardiovascular Surgery Sungkyunkwan University School of Medicine Samsung Medical Center, Korea
Young Mog Shim
Esophagectomy is followed by a high risk of severe complications and a detri-
after esophagectomy. The QOL decreased soon after the operation and nerve
mental impact on health-related quality of life (QOL). Hence quality of life after
injury especially recurrent laryngeal nerve injury is critical for QOL. The differ-
cancer surgery must be considered as a important part of treatment.
ences of QOL according to the surgical technique, route of anastomosis and the
In 1999, David Kirby, the chairman of the oesophageal patients association in
level of recovery are indefinite. Minimally invasive esophageal surgery can ele-
the UK published the article named Quality of life after esophagectomy: the
vate the QOL of esophagectomy.
patients perspective. As one of the patient who received esophagectomy, he
1. Djarv T, Blazeby JM, Lagergren P. Predictors of postoperative quality of life
claimed some points that the doctors might not concern. He summarized that
after esophagectomy for cancer. J Clin Oncol. 2009; 27(12): 1963-8.
key element of QOL after esophagectomy is to be able to eat adequately and
2. Kirby JD. Quality of life after oesophagectomy: the patients perspective. Dis
enjoy it, drink as desired, have weight stability, sleep comfortable in a normal
Esophagus. 1999; 12(3): 168-71.
position, etc. and he also summarized that the negative things, for example, sur-
3. Stoller JL, Samer KJ, Toppin DI, Flores AD. Carcinoma of the esophagus: a
vival statistics, negative statements by medical staff, or inability to do the same
new proposal for the evaluation of treatment. Can J Surg. 1977; 20(5): 454-9.
job as before could have a bad influence upon the patient s attitude.2 In this re-
4. Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-
port, he insisted that the esophagectomy is not the end of treatment but a start-
36). I. Conceptual framework and item selection. Med Care. 1992; 30(6): 473-83.
ing point of management due to many changes after surgery. So it is very im-
5. Blazeby JM, Alderson D, Winstone K, Steyn R, Hammerlid E, Arraras J, et al.
portant to evaluate the status of patients after esophagectomy for improving
Development of an EORTC questionnaire module to be used in quality of life as-
QOL of surgery.
sessment for patients with oesophageal cancer. The EORTC Quality of Life
3
In 1977, Stoller insisted new proposals for the evaluation of treatment of
Study Group. Eur J Cancer. 1996; 32A(11): 1912-7.
esophageal cancer. They were swallowing ability, work habits, the employ-
6. Blazeby JM, Conroy T, Hammerlid E, Fayers P, Sezer O, Koller M, et al. Clini-
ment of leisure, and sleeping habits. But patient s experiences of diseases and
cal and psychometric validation of an EORTC questionnaire module, the
treatment were not routinely collected because lack of valid methods of data
EORTC QLQ-OES18, to assess quality of life in patients with oesophageal can-
collection that are easy to use.4 Therefore making the instrument to assess
cer. Eur J Cancer. 2003; 39(10): 1384-94.
quality of life was important. There were many instruments. However the
7. Roder JD, Herschbach P, Ritter M, Kohn MM, Sellschopp A, Siewert JR. [The
medical outcome short form health survey (MOS SF-36) and EORTC (European
quality of life following esophagectomy. The results of a psychosocial study of
3
organization for research and treatment of cancer) quality of life questionnaire
80 cancer patients]. Dtsch Med Wochenschr. 1990; 115(15): 570-4.
were most widely used. MOS SF-36 was an advanced form of MOS SF 20 and
8. Collard JM, Otte JB, Reynaert M, Kestens PJ. Quality of life three years or
EORTC questionnaire improved from EORTC QLQ C30 to EORTC QLQ-OES
more after esophagectomy for cancer. J Thorac Cardiovasc Surg. 1992; 104(2):
184-6.
391-4.
In 1990s, there were some studies of QOL after esophagectomy but the ques-
9. Baba M, Aikou T, Natsugoe S, Kusano C, Shimada M, Nakano S, et al. Quality
tionnaire was not standardized7-9 but since 2000, standard form of question-
of life following esophagectomy with three-field lymphadenectomy for carci-
naires, MOS SF-36 or EORTC QLQ-OES 24 or 18, were used.
10-12
Various
noma, focusing on its relationship to vocal cord palsy. Dis Esophagus. 1998; 11
esophagectomy techniques, route of anastomosis, or complications were com-
(1): 28-34.
pared using these QOL tools and the surgical outcomes can be evaluated more
10. Headrick JR, Nichols FC, 3rd, Miller DL, Allen MS, Trastek VF, Deschamps
objectively and precisely with them. Some studies insisted that recurrent laryn-
C, et al. High-grade esophageal dysplasia: long-term survival and quality of life
geal nerve injury could decrease the QOL9 and physical symptoms and activi-
after esophagectomy. Ann Thorac Surg. 2002; 73(6): 1697-702; discussion 702-3.
ties returned toward baseline within first year of operation and transhiatal
11. de Boer AG, van Lanschot JJ, van Sandick JW, Hulscher JB, Stalmeier PF,
esophagectomy is better than transthoracic esophagectomy.11 Some authors
de Haes JC, et al. Quality of life after transhiatal compared with extended
claimed the QOL of the esophagectomy patients can be equivalent to that of the
transthoracic resection for adenocarcinoma of the esophagus. J Clin Oncol.
general population but the others insisted that it never reached preoperative
2004; 22(20): 4202-8.
levels again.13 Tumor location, stage or cell type may be prognostic factors of
12. Moraca RJ, Low DE. Outcomes and health-related quality of life after
QOL following esophagectomy.1 These days minimally invasive esophageal sur-
esophagectomy for high-grade dysplasia and intramucosal cancer. Arch Surg.
gery, such as thoracoscopic esophagectomy and robotic esophagectomy, are in-
2006; 141(6): 545-9; discussion 9-51.
creasingly used for the purpose of elevating the quality of life after esophagec-
13. Egberts JH, Schniewind B, Bestmann B, Schafmayer C, Egberts F, Faen-
tomy.
drich F, et al. Impact of the site of anastomosis after oncologic esophagectomy
In conclusion, quality of life after esophagectomy is very important. The stan-
on quality of life--a prospective, longitudinal outcome study. Ann Surg Oncol.
dard QOL tools, MOS SF-36 or EORTC OES-18, are effective for evaluating life
2008; 15(2): 566-75.
364
Symposium
E-SY4-3
E-SY4-4
The evolving role of esophagectomy in the era of
neoadjuvant chemoradiotherapy
Thoracoscopic esophagectomy in a prone position for
esophageal cancer: A preceding anterior approach
method
Department of thoracic surgery, Chang Gung Memorial Hospital, Taiwan
Yin Kai Chao, Liu Yun Hen, Wu Yi Cheng, Liu Hui Ping
Due to the anatomical location of the esophagus, tracheobronchial and aorta invasion commonly occurs following
extraesophageal spread in esophageal cancer patients and is
categorized as T4b(i.e. unresectable T4) in the 7th AJCC
staging system. The prognosis of T4b disease is poor and the
present therapeutic strategy remained controversial. Oncologist from Asia suggested the use of primary chemoradiotherapy(CRT) while NCCN 2013 guideline favored palliative
chemotherapy as the only treatment. Radiotherapy is not
used due to fear of lethal aorta!
trachea-esophageal fistula
formation.
Theoretically, neoadjuvant CRT has the potential to downstage tumor and thus complete resection might be possible
even in the setting of T4b disease. However, most reports on
neoadjuvant CRT in locally advanced esophageal cancers
have excluded T4b disease, limiting the applicability of those
results.
In today s presentation, I will briefly discuss the role of surgery in T4b patients after neoadjuvant CRT, with special
emphasize on patient selection, rate of fistula formation and
survival outcome.
Department of Gastroenterological Surgery, Tokai University
School of Medicine, Japan
Soji Ozawa, Junya Oguma, Akihito Kazuno,
Yasushi Yamasaki, Yamato Ninomiya
Background The rate of thoracoscopic esophagectomy for the treatment of
esophageal cancer was about 31% in Japan. Although this rate has been
gradually increasing, it remains relatively low, because of the difficulty in
maintaining a good surgical field and because of the meticulous procedures
that are required. A thoracoscopic esophagectomy performed while the patient is in a prone position may overcome the above problems. We established and evaluated a new procedure for performing a thoracoscopic
esophagectomy to make the esophagectomy easier to perform.
Patients and Surgical procedure We have performed thoracoscopic
esophagectomies using our new procedure in 100 patients with esophageal
cancer. The patients were placed in a prone position after intubation. Five
trocars were inserted into the right thoracic cavity. Only the left lung was
ventilated, and a pneumothorax in the right chest was created using 6
mmHg of CO2 gas. The anterior pleura of the upper posterior mediastinum
was incised around the right side of the trachea, and the lymph nodes
around the right recurrent laryngeal nerve were dissected. The esophagus
was mobilized from the trachea with the lymph nodes around the left recurrent laryngeal nerve during the first step. The esophagus was mobilized
from the posterior structure during the second step. The middle and lower
portions of the esophagus were also mobilized in the same manner as that
for the upper portion.
Results The mean patient age was 65.4 years, and there were 84 male patients (84%) and 16 female patients (16%). Thirty-eight patients (38%) received neoadjuvant chemotherapy. The median operative time for the thoracoscopic procedure was 210 min, and the median blood loss was 20 mL.
There were no conversions to a thoracotomy and no operative deaths in this
series. The following postoperative complications related to the thoracoscopic procedure occurred: 17 patients (17%) developed pneumonia and 16
patients (16%) developed recurrent laryngeal nerve palsy. No operative
deaths and no hospital deaths occurred in this series. The overall survival
rate for the 100 patients was 79% at 3 years after surgery.
Conclusions A thoracoscopic esophagectomy in a prone position for the resection of esophageal cancer using a preceding anterior approach is a safe
and feasible procedure. The main advantages of this method are that the
mediastinal organs are shifted downwards as a result of gravity and that the
surgical field for the posterior mediastinum eventually becomes wide open.
This method seems to make esophagectomies easier to perform.
365
Symposium
E-SY5-1
E-SY5-2
Advanced laryngeal cancer: Current treatment background and the future direction
Controversies in the management of advanced laryngeal and hypopharyngeal cancer
Department of Otorhinolaryngology-Head and Neck Surgery,
Kitasato University School of Medicine, Japan
Department of Head and Neck Surgery, University of Sao
Paulo School of Medicine, Brazil
Meijin Nakayama, Shunsuke Miyamoto, Yutomo Seino,
Tabito Okamoto, Koichi Kano, Makito Okamoto
Rogerio Dedivitis
!BACKGROUND!
The evolution of laryngology over the past 150 years has transformed laryngeal
cancer from the most feared to the most curable cancer 1) (Table). Total laryngectomy (TL) has long been an effective treatment option for advanced cancers.
The advent of platinum-based chemotherapy brought a new era of non-surgical
approaches in larynx preservation. Particularly after the two landmark trials
(VA trial and RTOG 91-11), there has been increasing use of chemoradiotherapy
(CCRT) with a decreasing use of TL. Despite many successful reports, it has become evident that a significant proportion of patients did not benefit from
CCRT because of untreatable local failures and severe late toxicities. In addition,
laryngeal cancer survival has decreased based on the recent US database.
!PATIENTS and RESULTS!
Our university hospital was established in 1972, which overlapped with the era
of the global treatment shift (Table). During the past 40 years, approximately
1000 laryngeal tumors were registered. Among them, 849 patients with
squamous cell carcinoma were chronologically analyzed; overall survival and
larynx preservation rates exhibited favorable improvements 2). A total dose of
60Gy-RT combined with S1 (an oral 5-FU derivative), showed superior effect in
treating T1-2 cancers. Supracricoid laryngectomy (particularly SCL-CHEP) contributed significantly to larynx preservation in advanced and RT failure cancers.
!CONCLUSIONS!
In larynx preservation, the patient s benefit should be considered before clinical
interests. Treatment selection should not merely be decided by guidelines, and
each patient s individual status needs to be taken into consideration. The weight
of larynx preservation options must be carefully balanced as potential complications and pitfalls do exist and may be beyond expectations; the role and benefits
of TL should always be taken into consideration and discuss with each patient.
The clues to the recover from the survival deterioration can be found in the description of the VA trial as organ sparing approaches require 1) ideal multidisciplinary team approach, 2) adequate compliance from patients, and 3) careful follow up.
!REFERENCES!
1) Nakayama M, Laccourreye O, Holsinger H, et al.: Functional organ preservation for laryngeal cancer: Past, Present, and Future. JJCO, 42:155-160, 2012.
2) Nakayama M, Okamoto M, Hayakawa K, et al.: Clinical outcomes of 849 laryngeal cancers treated in the past 40 years: Are we succeeding? JJCO, 44:57-64,
2014.
!TABLE LEGEND!
Milestones in larynx management (Table modified from Reference 1). Our 40
years experience overlapped with the era of the global treatment shift towards
CCRT.
366
The traditional treatment for advanced laryngeal cancer
was surgery with adjuvant radiotherapy, being total laryngectomy with neck dissection the surgical procedure of
choice. Despite reasonable oncological outcome, total laryngectomy is a treatment option that involves a major change
in the patient s life, mainly due to the definitive tracheotomy
and the loss of laryngeal voice. From the early nineties, some
studies showed improvement in results of treatment with radiotherapy and the association with chemotherapy, reaching
oncological outcomes similar to those obtained with surgical
treatment followed by radiation, with higher probability of
laryngeal preservation. Initially, sequential chemotherapy
and radiotherapy were proposed. However, the concomitant
approach achieved superior results. Thus, the surgical approach was not considered the treatment of choice in case of
moderately advanced laryngeal and hypopharyngeal tumors
in patients elegible for total laryngectomy and the organ
preservation protocols based on chemoradiation therapy became popular. However, posterior studies showed some decrease in overall survival among patients with laryngeal cancer after the nineties, in opposition to the results obtained
with the treatment of other tumor sites in the United States.
Such period is coincident with the popularization of the indication of nonsurgical treatment enabling the anatomical
preservation of the larynx of many patients. Furthermore,
the anatomical preservation of the organ did not correspond
systematically to its functional preservation. In locally advanced tumors (T4 tumors), better oncological outcome occurs under the surgical treatment. However, in case of locally moderately advanced tumors eligible to total laryngectomy (T3 and selected T4a tumors), there is some controversy. Most guidelines suggest that if there is no gross involvement of cartilage, nonsurgical treatment can be performed, but some studies show similar results even when advanced tumors are treated with chemoradiation. Induction
chemotherapy has been still considered an option, since the
initial chemotherapeutic approach could evaluate the clinical
response and indicate the responsiveness of further conservative protocol in order to avoid total laryngectomy.
Symposium
E-SY5-3
E-SY5-4
Current management strategy of laryngeal cancer and
hypopharyngeal cancer in China
The improvement of the treatment outcome in laryngeal cancer and hypopharyngeal cancer
Department of Otolaryngology-HNS, Eye & ENT Hospital of
FudanUniversity, China, China
Department of Otolaryngology Head and Neck Surgery, Kurume University School of Medicine, Japan
Tao Lei
Hirohito Umeno, Akiteru Maeda, Shun-ichi Chitose,
Takeharu Ono, Bu-ichiro Shin, Tadashi Nakashima
The management of laryngeal cancer and hypopharyngeal
cancer has fundamentally changed over recent years. The
optimum treatment protocols should pay close attention to
the survival rate and organ function preservation. The purpose we discussed to define the prevalence of intervention of
laryngeal cancer and hypopharyngeal cancer, such as open
operation, CO2 laser and non-operation treatment, and that
may facilitate standardization of such practices.
We also retrospectively reviewed 386 patients with hypopharyngeal cancer treated in Otolaryngology-HNS Department of EENT Hospital of Fudan University from 2003 to
2012, including 370 males and 16 females. The median age
was 58.43 9.45 years old, ranged from 38 to 82 years old. All
the tumors originated from the pyriform sinus (295, 76.4%),
posterior pharyngeal wall (68, 17.6%), and postcricoid area
(23, 6.0%). There were no distant metastases. 21 patients received radiotherapy or induction chemotherapy preoperatively, and 180 patients received radiotherapy, chemotherapy or targeted therapy postoperatively. 42 patients (10.9%)
were surgically treated with partial phayngectomy, 43 patients (11.1%) with partial laryngopharyngectomy, 232 patients (60.1%) with total laryngectomy with partial phayngectomy, 12 patients (3.1%) with total laryngopharyngectomy,
and 57 patients (14.8%) with total laryngopharyngectomy
and esophagectomy. Pharyngoesophageal defect reconstruction methods in case with laryngeal functions preserved
were: direct suture in 284 cases, stomach pulling-up in 54
cases, pectoralis major musculocutaneous flap in 32 cases,
free forearm flap in 11 cases, neck myocutaneous flap in 3
cases, latissimus dorsi flap in 1 cases, split graft in 1 cases. In
335 out of 386 patients (86.8%) received modified neck dissection, including 278 patients both unilateral and 57 patients bilateral.
Keyword: laryngeal cancer, hypopharyngeal cancer, intervention, organ function preservation
Between 1971 and 2011, 1306 laryngeal cancer and 532 hypopharyngeal cancer patients without distant metastasis were
radically treated at the Kurume University Hospital. So far,
primary laryngeal cancer has been treated by several methods as follows, radiotherapy with or without chemotherapy,
tansoral CO2 laser microsurgery with or without radiotherapy, partial laryngectomy, radiation and concomitant intraarterial cisplatin (RADPLAT) and total laryngectomy. The
method of treatment was chosen according to the lesional
state, general condition and patient s desire. Supra-cricoid
subtotal laryngectomy has also been done as a salvage surgery for the recurrent cancer patients after the radiotherapy. In reviewing the treatment method in our hospital, it
has changed dramatically from 1994. Before 1994, partial laryngectomy was usually selected as a first therapy for T2 or
T3 laryngeal cancer. However, CDDP based concurrent
chemo-radiotherapy was introduced since 1994. RADPLAT
was introduced since 2004. The supra-cricoid subtotal laryngectomy was introduced since 2007. As a result by absence
treatments, 5year overall survival rate and 5year laryngeal
preservation rate significantly improved after 1994 as compared to 1994 and before.
Primary hypopharyngeal cancer has been treated by several
methods as follows, radiotherapy with or without chemotherapy, tansoral CO2 laser microsurgery with or without
(chemo) radiotherapy, partial pharyngectomy with or without laryngectomy, RADPLAT and total pharygo-laryngoesophagectomy. The method of treatment was chosen according to the lesional state, general condition and patient s
desire. Disease-free 5year survival rate and overall survival
rate of total laryngeal cancer were 88.9% and 74.5%. On the
other hand, Disease-free 5 year survival rate and overall survival rate of total hypopharyngeal cancer were 56.4 and
41.9%. 5year local control rate and laryngeal preservation
rate of laryngeal cancer were 88.4% and 62.7%. On the other
hand, 5year local control rate and laryngeal preservation
rate of hypopharyngeal cancer were 84.3% and 28.5%. In reviewing the treatment method in our hospital, it has changed
dramatically from 1989. After 1989, free intestinal reconstruction surgery after total pharyngo-laryngo-esophagectomy
has been started for advanced hypopharyngeal cancer. A
transoral CO2 laser microsurgery with or without (chemo)
radiotherapy has been started in 1995. CDDP based concurrent chemo-radiotherapy, RADPLAT were introduced after
2000. As a result by absence treatments, 5year disease free
and overall survival rate and 5year local control rate and laryngeal preservation rate significantly improved after 1989
as compared to 1989 and before.
367
Sponsored Seminar
E-SS
Development history and concept of an oral anticancer agent S-1 (TS-1): Its clinical usefulness and future
vistas
Department of Surgery, Miyagi Cancer Center, Japan1), Kitasato Institute for Life Science, Kitasato University, Japan2)
Koh Miura1), Tetsuhiko Shirasaka2)
Heidelberger et al. left a great gift to human beings by discovery of 5-fluorouracil (5-FU). Approximately 40 years
elapsed from the discovery of 5-FU to the development of S1. 5-FU is now used as a core drug in widely accepted international standard regimes for the treatment of gastrointestinal cancers.
The concept of developing an anticancer agent that simultaneously possesses both efficacy-enhancing and adverse
reaction-reducing effects, could be achieved only with a 3component combination drug. S-1 (TS-1) is an oral anticancer
agent containing 2 biochemical modulators for 5-FU and
tegafur (FT), a metabolically activated pro-drug of 5-FU. The
first modulator, 5-chloro-2,4-dihydroxypyridine (CDHP), enhances the pharmacological actions of 5-FU by potently inhibiting its degradation. The second, potassium oxonate
(Oxo), localizing in mucosal cells of the gastrointestinal (GI)
tract after oral administration reduces the incidence of GI
toxicities by suppressing the activation of 5-FU in the GI
tract. Thus S-1 combines FT, CDHP, and Oxo at a molar ratio of 1:0.4:1, and since 1999-2007 it has been approved for the
treatment of following seven cancers: gastric, head and neck,
colorectal, non-small cell lung, breast, pancreatic, and biliary
tract cancers in Japan. The standard regimen in clinical setting was with the recommended daily dosing of S-1 for 4
weeks followed by 2 weeks of drug withdrawal.
Furthermore, alternate-day S-1 regimen (alternate-day dosing on Monday, Wednesday, Friday, and Sunday per week)
may be considered as the most patient-friendly therapies
that are available up-to-date and allowing a long-lasting treatment with no or little hematologic toxicities and also a neglectable nonhematologic toxicities within Grade 1 or below.
Now, two multicenter Randomized Clinical Trials of S-1 for
the Advanced Gastric (JFMC-43-1003 Study) and Pancreatic
Cancer patients (PAN-01 Study) are ongoing in Japan.
The alternate-day regimen of S-1 in combination with other
anticancer drugs may become the next standard therapies,
making possible the long-lasting treatment of cancer patients. We are fully confident that balancing between the efficacy and toxicity of an anticancer agent, conferring survival benefit to cancer patients , will definitely contribute to
their routine medical care.
368
Luncheon Seminar
E-LSF
E-LSJ
Evaluation and management of laryngopharyngeal reflux
A paradigm shift: Reasons for the change to primary
TEP with prosthesis placement
Otolaryngology-Head & Neck Surgery, Yokohama City University Graduate School of Medicine, Japan1), Hokkaido University Japan2), Health Sciences University of Hokkaido, Japan3), Hokkaido University, Japan4)
Nobuhiko Oridate1), Yukiko Ikui1), Daisuke Sano1),
Takahide Taguchi1), Masahiro Takahashi1),
Goshi Nishimura1), Osamu Shiono1), Masanori Komatsu1),
Akihiro Homma2), Noriko Nishizawa3), Hiroshi Takeda4)
Background: According to reports from Western countries, patients with laryngopharyngeal reflux (LPR) rarely complain of
the typical symptoms of gastroesophageal reflux disease (GERD),
such as heartburn and acid reflux, but there has not been a detailed study in Japanese LPR patients.
Aim: The aim of this study was to evaluate upper abdominal
symptoms in LPR patients and changes in both upper abdominal
and LPR symptoms before and after acid-suppression therapy
and also to determine whether a pretreatment questionnaire using the Frequency Scale for the Symptoms of GERD (FSSG)
could predict the therapeutic effect on LPR symptoms.
Methods: The subjects were 125 patients who presented at the
Department of Otolaryngology at the Hokkaido University Hospital complaining of LPR symptoms and who were not on acidsuppression therapy. Their upper abdominal symptoms were
evaluated using the FSSG, which is a new method of assessing
GERD and covers the 12 most common symptoms of GERD.
Their LPR symptoms were evaluated using the LPR symptom
scoring system. Subjects were then administered acidsuppression therapy (rabeprazole 20 mg!day) for at least 4
weeks. In the 60 assessable patients, changes in upper abdominal
and LPR symptoms before and after treatment were evaluated.
Results: According to the FSSG some upper abdominal symptoms were reported by 118 of the 125 subjects with LPR. Acidreflux-related symptoms are not necessarily more common; indeed, the frequency of dysmotility-like symptoms is similar.
There was poor correlation between the positive rates for FSSG
upper abdominal symptoms and the frequency of laryngopharyngeal symptoms.
In the 60 assessable subjects who underwent at least 4 weeks of
acid-suppression therapy, statistically significant reductions
were observed in the frequency of acid-reflux-related symptoms,
dysmotility-like symptoms, and laryngopharyngeal symptoms after acid-suppression therapy. The LPR symptom (Question 7 in
FSSG) was resolved in 9 patients, improved in 26 patients, and
unchanged or worse in 18 patients. There was no significant difference among these groups both in the pretreatment and posttreatement frequency of any of the upper abdominal symptoms.
Conclusions: The majority of Japanese LPR patients experience
some form of upper abdominal symptoms. Acid-reflux-related
symptoms are not necessarily more common; indeed, the frequency of dysmotility-like symptoms is similar. There was no
correlation between the positive rate for FSSG upper abdominal
symptoms and the frequency of laryngopharyngeal symptoms.
These findings indicate that in LPR patients, the laryngopharyngeal symptom question of the FSSG is an independent question,
unrelated to any of the other questions.
Head and Neck Institute, Cleveland Clinic Foundation, USA
Brian B. Burkey
Objective: Tracheoesophageal puncture (TEP) in the United
States has historically been created either primarily or secondarily, with placement of a stenting catheter, followed by
prosthesis placement days later (secondary fit). Recently,
studies in Europe have suggested that primary TEP with
primary fitting of the voice prosthesis can be a safe, effective
option. Our institution changed our standard technique from
secondary placement of prostheses to primary fitting. This
study looks to compare the safety, efficacy and cost profile of
primary TEP and fit with conventional techniques, based on
a comparison of findings before and after our paradigm shift.
Method: Single-institution cohort study of patients who underwent total laryngectomy with primary or secondary tracheoesophageal puncture, with primary or secondary fit, between 2009 and 2013. Voice outcome was assessed as voice
production at the first postoperative appointment and TEP
usage at 6 months and 1 year following puncture. Perioperative emergency department (ED) visits, post-operative pharyngocutaneous fistula and stomal breakdown were analyzed using statistical software.
Results: Ninety patients were included, of which 47 had preoperative radiation. Fifty-seven were reconstructed with a
fasciocutaneous free flap, while 28 were closed primarily.
Seventy-three had primary TEPs, of which 32 were catheter
stented and 41 were fitted primarily. The remainder had secondary TEPs, and approximately half of these were primarily fit.
Patients with primary fittings were significantly less likely to
come to the ED in the two months following surgery (14% vs.
39%, p<0.01). Among the primary TEP patients, pharyngocutaneous fistula rates were similar whether the voice prosthesis was fitted primarily or secondarily, and there was no increase in stomal breakdown. There was no difference in the
same wound complication rates between primary versus
secondary punctures.
Among patients with primary punctures, primary fit patients had higher rates of initial voice success compared to
secondary fit patients, although this was not statistically significant. At 6 months and 12 months after surgery, primary
fit patients trended toward higher rates of TEP usage, but
again this was not statistically significant.
Primary puncture and fit may decrease costs by eliminating
a second surgery and reducing post-operative ED visits. Preliminary cost analysis shows that conversion from secondary
TEP and primary TEP with secondary fit to primary TEP
and fit leads to significant monetary and resource savings.
Conclusion: Primary TEP with primary voice prosthesis
placement represents a safe, successful and cost-effective approach to vocal rehabilitation following total laryngectomy.
369
Luncheon Seminar
E-LSM
Three-dimensional evaluation of laryngotracheal region using cone-beam computed tomography
Otolaryngology-Head and Neck Surgery, Keio University
School of Medicine, Japan
Koichiro Saito
Cone beam computed tomography (CBCT) was developed
for the office-based quick and precise 3D visualization of
maxillofacial region. CBCT requires scanning time of less
than 10 seconds and provides isotropic 3D image with high
resolution. While multiple studies proved the feasibility of using multi-slice helical computerized tomography for visualizing the laryngotracheal region, only a few studies reported
the application of CBCT for the evaluation of this region.
This novel technology realized the precise measurement of
human organs with an error by less than one millimeter.
Furthermore, different from the conventional CT recording,
CBCT images are obtained with the patients in sitting position, relatively more natural to analyze the shape and size of
live human airway.
We have reported the accurate size and shape of paralyzed
larynges in Japanese patients measured by CBCT imaging.
To obtain the images with and without laryngeal muscle contraction, laryngeal CBCT images were taken in two conditions. Data were composed of 1) images taken with the patients sitting relaxed, and 2) images taken with the patients
applying pressure at their diaphragm. Images were useful
not only for research use, but also for clinical practice to explain the pathology of diseased larynges to the patients and
their families. Furthermore, CBCT served informative images for choosing proper phonosurgical procedure to treat
glottic insufficiency. We have also reported a case of laryngeal stenosis in which CBCT images were helpful for both
pre- and post-operative evaluation of the lesion. Balloon
catheter technique was used in this female patient and preoperative images clarified the shape of her stenotic lesion to
select proper size of the catheter. Postoperative images allowed us to measure the impact of the surgical intervention.
Recently, virtual endoscopy based on the isotropic CBCT
data came to be available as a potential next-generation diagnostic tool. In this seminar, previous reports on CBCT application for laryngotracheal region are reviewed. Our practical
experiences to utilize CBCT imaging technology for both research and clinical use are also presented.
370
Oral Presentation
E-O1-1
E-O1-2
A diagnostic meta-analysis of sentinel lymph node biopsy in early head and neck squamous cell carcinoma
Post-therapeutic laryngeal function and QOL after radiotherapy or laser surgery against early glottic cancer
Department of Otolaryngology, Head and Neck Surgery, Kyorin University School of Medicine, Japan
Dai Sato, Koichi Yamauchi, Yasunao Kogashiwa,
Naoyuki Kohno
Background: The sentinel lymph node biopsy (SLNB) concept has been gaining support in the head and neck cancer
literature during only the last few years, and several pilot
studies have been published. However, many of these were
single-center reports with a limited number of cases. And so
we performed a diagnostic meta-analysis of SLNB in early
head and neck squamous cell carcinoma (HNSCC).
Methods: The PubMed database was searched for studies
about SLNB in early HNSCC before October 31, 2012. Pooled
values for the sentinel lymph node identification rate, sensitivity, false-negative rate, negative predictive value, and accuracy were calculated.
Results: A total of 16 studies (987 patients) was included. The
pooled identification rate, sensitivity, false-negative rate,
negative predictive value, and accuracy were 95.2%, 86.3%,
13.7%, 94.2%, and 95.0%, respectively. The subgroup with
high methodological quality showed a mean sensitivity of
91.0% for SLNB feasibility study and 84.2% for SLNB clinical
study, and mean false-negative of 9.0% for SLNB feasibility
study and 15.8% for SLNB clinical study.
Conclusions: The SLNB procedure has shown a high sensitivity rate, but the pooled sensitivity and false-negative rate
were worse in SLNB clinical study than in SLNB feasibility
study.
Department of Otolaryngology Head and Neck Surgery, Keio
University School of Medicine, Japan1), Department of Otolaryngology, Kawasaki Municipal Ida Hospital, Japan2)
Takeyuki Kono1), Koichiro Saito1), Haruna Yabe2),
Kosuke Uno1), Kazumi Asano1), Asuka Yamamoto1),
Yoshie Iino1), Kaoru Ogawa1)
[Background] Both CO2 Laser surgery (LS) and Radiotherapy (RTx) are commonly used for early glottic cancer. However, superiority of either treatment options still remains
controversial. The purpose of this study was to comparatively assess the laryngeal function and QOL of the patients
after LS or RTx against early glottic cancer.
[Method] Sixty-four patients with T1 glottic cancer treated
with radiotherapy (n=27) or CO2 laser surgery (n=37) were
incorporated in this retrospective cohort study. LSs were
performed following the type II subligamental cordectomy
concept. Patients in LS group were categorized into subgroups for further analyses. Twenty-two patients had vaporization of the lesion with defocused mode (LS-Vap group),
and 15 patients had cancer excision with focused super
pulsed mode using relatively lower power (LS-Ex group).
GRBAS scale, maximum phonation time, and acoustic parameters were evaluated to measure glottal function. VRQOL and VHI were utilized to evaluate post-therapeutic
QOL of the patients. Laryngeal videostroboscopic images
were further examined to assess post-therapeutic laryngeal
pliability. To investigate time-dependent changes of laryngeal function, multiple parameters were measured at the
time points of pre-therapy, 1, 3, 6, and 12 months after therapy. The mean follow-up period was 46 months.
[Results] Five patients who had residual tumor or recurrence during follow-up period were excluded. RTx group revealed significantly better vocal function compared with LS
group both in subjective and objective analyses. In further
subgroup analyses, GRBAS scores in LS-Vap group turned
worse shortly after treatment compared with those in LS-Ex
group, while the scores recovered to the pre-therapeutic
level 6 months after treatment in both groups. Stroboscopic
investigations revealed abnormal glottal closure, symmetry
and mucosal wave pattern in over 80% of the patients in LSVap group 1 year after treatment. However, complete glottal
closure was observed in more than half of the patients in
either RTx group or LS-Ex group 6 months after treatment.
While the symmetry of the vocal folds were observed in
around 40% of the patients in both groups, recovery rate of
mucosal wave was relatively better in RTx group (over 60%)
compared with LS-Ex group (over 40%) 1 year after treatment.
Residual comparative analyses proved equivalent posttherapeutic vocal function and QOL in RT group and LS-Ex
group better than those in LS-Ex group.
[Conclusion] Early glottic cancer could be successfully
treated by either radiotherapy or focused super pulsed low
power CO2 laser surgery with equivalent post-therapeutic
laryngeal function and QOL.
371
Oral Presentation
E-O1-3
E-O1-4
Laryngeal leukoplakia in non-smokers-who requires biopsy?-
Utility of high-definition nasopharyngoscope with iscan for determining margin in transoral videoassisted surgery
Department of Otolaryngology, Keio University School of
Medicine, Japan1), Department of Otolaryngology, Kawasaki
Municipal Ida Hospital2)
Kosuke Uno1), Koichiro Saito1), Takeyuki Kono1),
Haruna Yabe2), Kaoru Ogawa1)
Laryngeal leukoplakia is a frequent clinical pathology in the
ENT clinic with diverse potential histopathology including
inflammation, dysplasia, and cancer. It is well-known that
leukoplakia is highly suspicious of (pre-)malignant lesion in
smokers. Although most of laryngeal leukoplakias are inflammatory lesions in non-smokers, part of them require careful
diagnoses and treatments even in this low-risk group. In this
study, clinical courses of the patients with laryngeal
leukoplakia were reviewed to comprehend the clinical characteristics of this frequent pathology. Further subgroup
analyses were performed on non-smokers to clarify the key
findings to distinguish the patients who require cautious
care from others not to miss the serious histopathology in
this low-risk group.
From June 2006 to May 2013, 154 consecutive patients referred to our voice clinic with laryngeal leukoplakia. Of
these, 9 patients ceased visiting our institution by their own
decisions and were excluded from this study. Spontaneous
disappearance or regression of the lesions were observed in
42 patients (29.0%), while 103 patients (71.0%) underwent biopsies for histopathological diagnoses. Smoking histories
were observed in 121 patients (S group) and residual 24 patients were non-smokers (NS group). Histopathological findings were divided into 3 categories of 1) no dysplasia (ND), 2)
mild to moderate dysplasia (MM), and 3) severe dysplasia to
squamous cell carcinoma (SS). Most of the SS patients required additional therapies, and the rate of SS was relatively
higher in S group (n=44, 36.4%) compared with NS group
(n=5, 20.8%). Further subgroup analyses were performed on
the patients in the NS group using GRBAS subjective voice
assessment scale and stroboscopic findings. On average,
spontaneous disappearances of the lesions were observed 4.6
months after referral to our hospital in 7 patients. These patients represented vocal quality of G1 or G0 at their first
presentation. Furthermore, gradual recovery of their glottal
closure and!
or pliability of the vocal folds were observed
even in the patients with abnormal stroboscopic findings at
their first visits. Additionally, SS patients presented either 1)
no improvement in their G2 voice for 1 month, 2) no improvement in incomplete glottal closure coupled with diseased pliability for 1 month, or 3) no improvement in diseased pliability for 4 months.
Our study showed the demographic feature of laryngeal
leukoplakia, especially in non-smokers. Our analysis further
clarified several specific findings to distinguish the patients
who require cautions care from others not to miss the serious histopathology in this low-risk group.
372
Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine Tottori University, Japan1), Department of
Adult and Elderly Nursing, Tottori University Faculty of
Medicine, Japan2)
Takahiro Fukuhara1), Kazunori Fujiwara1),
Aigo Yamazaki1), Eiji Takeuchi1), Hideyuki Kataoka2),
Hiroya Kitano1)
Background: The combination of the nasopharyngoscope
VNL-1590STi (HOYA Corporation, PENTAX, Tokyo, Japan) and the processor EPKi generates high-definition images which have not been possible previously in the head
and neck region. The EPKi processes images with imageenhanced technology known as i-scan . I-scan has three
modes of image enhancement. One of them, tone enhancement called i-scan TE, that changes the tone curve of the
combination of RGB components, is quite effective mode to
enhance irregular mucosal lesion. The aim of this study is to
find out the effectiveness of the VNL-1590STi with i-scan and
Lugol s chromoendoscopy to determine surgical margin in
transoral resection of oropharyngeal or hypopharyngeal cancers.
Patients and Methods: 13 patients with oropharyngeal or hypopharyngeal cancer underwent transoral resection in Tottori university Hospital between April 2012 and October
2013. In all patients, we used the VNL-1590STi with i-scan
and chromoendoscopy during operations and determined
the surgical margins. After each operation, we checked the
margins of resected specimens pathologically.
Results: In all cases, abnormal mucosal patterns were detected clearly with the VNL-1590STi and i-scan TE and chromoendoscopy. The imaging enhanced with i-scan TE produced by EPKi processes made the margin of mucosal
changes detect easily and clearly. Especially the imaging, enhanced with i-scan TE that emphasized tone curve of blue
and green mainly, enhanced the mucosal changes and irregular mucosal vessels. Furthermore, the imaging emphasizing red tone curve mainly enhanced Lugol-voiding lesions
that were white color. Reviews of resected specimens shown
that with all patients the lesions including carcinoma in situ
had been resected.
Conclusion: The VNL-1590STi with i-scan and chromoendoscopy is concluded to be effective for more precise resection
in transoral resection of oropharyngeal or hypopharyngeal
cancers. I-scan TE may lead to improvement of the accuracy
of detection for early mucosal lesions.
Oral Presentation
E-O2-1
E-O2-2
Early detection and endoscope assisted resection of
pharyngeal cancer with narrow band imaging technique
Office-based NBI guided-flexible laryngoscopic tissue
sampling: A safe and effective new technique
Department of Otolaryngology-Head & Neck Surgery, Graduate School of Medicine, Kyoto University, Japan1), Department
of Therapeutic Oncology, Graduate School of Medicine, Kyoto
University, Japan2)
Ichiro Tateya1), Manabu Muto2), Shuko Morita2),
Shigeru Hirano1), Morimasa Kitamura1), Yo Kishimoto1),
Seiji Ishikawa1), Juichi Ito1)
[Background and purpose]
Pharyngeal cancer is often advanced when detected and has relatively poor prognosis. Early detection of the tumor is important because it not only improves survival rate but also minimizes functional loss of swallowing and voice. We have previously reported
that narrow band imaging (NBI) combined with magnifying endoscopy is useful in detecting early superficial pharyngeal cancers,
which are difficult to detect with a standard endoscopy. For such
cases, we are performing endoscope assisted submucosal dissection applying endoscopic submucosal dissection technique which is
increasingly used for early esophageal cancer. In this study, we investigated the usefulness of endoscope assisted submucosal dissection for early pharyngeal cancer.
[Operation procedure]
The procedure is performed by an otolaryngologist and a gastroenterologist assists the procedure by manipulating a gastroscope to
obtain an optimal surgical field. Under general anesthesia, specially
designed curved laryngoscope was inserted to allow a working
space in the pharyngeal lumen and a gastroenterologist inserts a
magnifying gastroscope (GIF TYPE H260Z; Olympus, Tokyo) with
high resolution transorally to visualize the field. The extent of the
lesion was determined by NBI and iodine staining and the margins
of the lesion are marked with coagulation. Cutting and dissection
procedure was performed with an orally inserted curved electric
knife. Fasting period was usually 1-2 days after operation.
[Results]
Since September 2007, 111 cancer lesions were removed from 71
patients with superficial pharyngeal cancer. Tumor origin was 68%
in the hypopharynx and 32% in the oropharynx. Regarding adverse effects, subcutaneous emphysema temporally occurred in 8
cases, all of which treated conservatively. Two cases needed emergency tracheostomy, one of which was due to post operative bleeding and the other was post operative musosal edema in addition to
the preexisting bilateral vocal fold paralysis.
During the median follow-up period of 24 months, local recurrence
occurred in 3 cases, one of which controlled by the same procedure
and two cases controlled by concurrent chemoradiotherapy. Post
operative neck lymph node metastasis occurred in 2 cases and both
were controlled by neck dissection. All patients survive with no
evidence of disease and retain their speaking, breathing, and swallowing functions.
[Conclusions]
Endoscope assisted submucosal dissection for early pharyngeal
cancer allows excellent survival and the preservation of swallowing and voice functions. Early detection of superficial pharyngeal
cancer with narrow band imaging technology and the treatment
with endoscopic submucosal dissection can be a new treatment
strategy for the head and neck cancer.
Department of Otolaryngology, Chang Gung Memorial Hospital, Taipei, Taiwan
Tuan-Jen Fang
Objective: As the advancement of distal chip laryngoscopy
and imaging system, office based procedures became more
common and as a regular service in laryngology clinics.
Office-based NBI guided-flexible laryngoscopic tissue sampling for laryngopharyngeal lesions has been introduced to
our clinic since 2010. Unlike the conventional technique, it
can be undergone in awaked patients without intubation and
sedation. The aim of project is evaluating the feasibility, accuracy and cost-effectiveness of the novel technique.
Methods: A retrospective review was made for cases had accepted office-based NBI guided-flexible laryngoscopic tissue
sampling for laryngopharyngeal lesions since Jan 2010 to
Feb 2013. We attempted to analyze the sensitivity and specificity of diagnosis by imaging and the accuracy from NBI
guided tissue sampling. The outcomes in cases with difficult
airways were emphasized.
Results: There were 90 cases had accepted the procedures.
Forty-three of them had previous head and neck cancer
treatment. All except one case completed the procedure and
left without complications. The sensitivity of malignancy in
laryngopharyngeal cancer by NBI imaging is 97.2% with
100% in specificity. The accuracy of first-bite tissue sampling
is 94.3%. The correlation of accuracy of biopsy is insignificant
with the size of tumor (T-satge) and the experience of procedure provider (comparing the first 30 to the last 60 cases).
The cost for patients undergoing office-based NBI flexible laryngoscopy tissue sampling is significant lower than conventional direct laryngoscopy in the operation room (p<0.001).
Conclusions: Office-based NBI flexible laryngoscopy tissue
sampling is a novel technique with a short learning-curve
and cost savings. For biopsy of laryngopharyngeal lesions, it
is a safe and effective alternative.
373
Oral Presentation
E-O2-3
E-O2-4
Lymph node metastasis in burns space
Utility of real-time ultrasound elastography in patient
with thyroid gland cancer
Department of Otolaryngology-Head & Neck Surgery, Hokkaido University Graduate School of Medicine, Japan
Akihiro Homma, Hiromitsu Hatakeyama,
Takatsugu Mizumachi, Jun Furusawa, Satoshi Kano,
Tomohiro Sakashita, Satoshi Fukuda
<Background>Burns space is a narrow space between the
deep and superficial layers of the cervical fascia above the
manubrium of the sternum. Sun G, et al reported that lymph
node metastasis existed in 22.6% of 115 patients underwent a
neck dissection including Burn space with papillary thyroid
cancer with clinically lymph node metastasis [Head Neck 35:
1168-70, 2013].
<Purpose>To analyze clinical and pathological factors
among patients with metastasis in Burns space.
<Patients>There were 2 patients who had lymph node in
Burns space preoperatively and confirmed them positive pathologically. Both of them had well differentiated papillary
carcinoma and multiple lymph node metastasis. We have not
dissected Burns space prophylactically in other patients with
papillary thyroid cancer, but no patient had recurrence in it
so far.
<Conclusions>Burns space is not usually dissected in patients with thyroid cancer. But Burns space metastasis occurred occasionally in patients with multiple lymph node metastases. We consider dissection of Burns space should be
done when preoperative examination suggest lymph node
metastasis in it as dissection of Burns space is less invasive,
easy to do, and not time consuming. We should pay attention
to Burns space in thyroid cancer management.
374
Department of Otolaryngology, Shimane University of Medicine, Japan
Yukie Hotta, Noriaki Aoi, Ichiro Morikura,
Takafumi Fuchiwaki, Shimizu Yasuhiko,
Shimizu Kanako, Hideyuki Kawauchi
The purpose
Real-time Ultrasound Elastography(USE) is Developed by Hitachi Medico at 2003.
With a simple operation only by putting the probe same as that
used for normal examinations on the body surface and applying
slight compression, elastic image can be obtained in real time.
Hard tumors compared with the surrounding can be displayed
in blue. The purpose of this study is to evaluate utility of USE
for the diagnosis of intraglandular metastasis and for an appropriated decision making of surgical resection area, preoperation
examination.
Subjects and Methods
The study included 85 patients who underwent a preoperative
elastography and thyroidectomy. (male 18 case, female 67 cases)
The histological results presented thyroid carcinoma 48 cases,
and Benign Tumor 37 cases. Evaluation of elasticity by USE
The elasticity was in degree scored as 1 (low), 2 (intermediate),
or 3 (high), according to the report by Rogo et. Al.
Results
USE findings of all examined nodules, All nodules were divided
into three groups score1, score2, score3. Sensitivity: 91.2%
Specificity: 83.7% Positive predictive value: 91.2% Negative predictive value: 83.8%
USE findings of examined nodules that was diagnosed papillary
carcinoma and benign tumor. Sensitivity: 92.3% Specifitivity:
93.9% Positive predictive value: 96% Negative predictive value:
86.1%
Comparison of CT findings and the Elastography findings.
Ordinary CT scan was able to detect thyroid tumors in bilateral
Lobes in 10 out of 27 patients. On the other hand, USE is available to find out thyroid malignant tumor in bilateral lobes of 13
patients among those
Conclusion
Ultrasound elastograpy is a useful tool
1 Diagnosis of intraglandular metastasis in patients with thyroid cancer
2 Appropriate decision making of surgical resection of thyroid
gland
Otherwise papillary cancer may recur in residual thyroid gland
postoperatively
Discusssion and futre goal
According to the previous reports on USE, Thyroid tumors being displayed green by USE, were reported to be a benign tumor, even with a lower percentage of malignancy (0-3%).
Thyroid tumors being displayed blue by USE, were reported to
be mostly a malignant tumor (73-100%).
Future Goal; The diagnostic criteria of USE is still elusive, and
therefore it is important to establish it, by mounting cases of
USE in patients with thyroid tumor
Thank you for your kind attention.
Oral Presentation
E-O3-1
E-O3-2
Stable regeneration of tracheal wall using autologous
chondrocytes and epithelial cells
Tracheal reconstruction with asymmetrically porous
polycaprolactone!
pluronic F127 membranes
Department of Otolaryngology Head and Neck Surgery, Kurume University School of Medicine, Japan
Shintaro Sueyoshi, Shun-ichi Chitose, Kiminori Sato,
Mioko Fukahori, Takashi Kurita, Hirohito Umeno,
Tadashi Nakashima
Background
For patients with malignant tumors or congenital or iatrogenic tracheal stenosis, surgical managements are often required. Extensive tracheal resection poses one of the most
challenging clinical problems. Several approaches for tracheal replacement have been reported, including the use of
autologous tissues. However, a completely satisfactory procedure has not yet been achieved. Since tissue engineered
trachea seeded with chondrocytes alone easily becomes infected, in most cases either its lumen becomes narrow or tracheal wall is lost. We hypothesize that tissue engineered trachea requires epithelium as a physical barrier and to regulate the metabolic functions of airways. The purpose of this
study is to regenerate tracheal wall using organotypic cultured tissue composed of autologous chondrocytes and epithelial cells.
Methods
Specimens of canine auricular cartilage(5-by-5-mm) and oral
mucosa (3-by-3-mm) were harvested. Chondrocytes and epithelial cells were isolated from each specimen. After a 2week cultured period the proliferated chodrocytes with a
high density of 1 107 cells!
ml were suspended in atelocollagen gels. Poly-lactic-glycolic acid (PLGA) block as an implant
carrier was placed into the cell-suspended gels. At the same
time, the cultured epithelial cells were seeded on the upper
surface of the block containing the three-dimensional cultured chondrocytes. After an additional 2-weekco-cultured
period, the tissue-engineered tracheal wall was transplanted
into a partially excised trachea. Seven weeks after the transplantation, the trachea was removed. The morphological
characteristics of the regenerated tracheal tissue were examined.
Results
We successfully fabricated the tissue-engineered tracheal
wall. Safranin-O and toluidine blue staining showed that the
fabricated tissue was organized into hyaline cartilage composed of cartilage matrices and chondrocytes contained in
cartilage cavities. Epithelium was identified overlaying the
cartilaginous tissue. Regarding the removed tracheal tissue,
the original luminal shape was preserved without deformation or atrophy. Histological examination showed the presence of mature hyaline cartilage covered with pseudostratified ciliated columnar epithelium.
Conclusion
Organotypic cultured tissue consisting of autologous chondrocytes and epithelial cells successfully restored the tracheal wall.
Department of Otorhinolaryngology-Head and neck surgery,
College of Medicine, Seoul National University, Korea1), Department of Advanced Materials, Hannam University, Republic of Korea2)
Seong Keun Kwon1), Kwang Hyun Kim1),
Myung-Whun Sung1), Dong Wook Kim1), Hyun Chang1),
Jin ho Lee2)
Background:
Although tracheal stenosis is a rare disease, the mortality
rates for patients with long-segment tracheal stenosis and
atresia are nearly 77% and 100%, respectively. Ssurgical reconstruction using end-to-end anastomosis can be performed
in many cases with a successful outcome. However, the generally accepted limit for tracheal resection is approximately 6
cm in adults, or approximately 50% of the original tracheal
length, with a smaller percentage available for resection in
the pediatric population. Trachea replacements using prosthetic or biological substitutes have thus far yielded unsatisfactory results, preventing their clinical application. The failures of these methods have been mainly because of donor site
restrictions, immunologic complications, bacterial infections,
an excessive time required for tissue culture, the need for a
second stage operation, material failure, and tracheal lumen
obstruction. The purpose of this study was to evaluate the efficacy of an asymmetrically porous membrane (APM) to induce tracheal reconstruction by inhibition of granulation tissue growth into the tracheal lumen whereas minimizing graft
failure.
Methods:
The APM was fabricated with polycaprolactone (PCL) and
pluronic F127. The top side of the membrane had nano-size
pores, whereas the bottom side had micro-size pores, and
both sides were connected by an asymmetric column-shape
pore structure. Fifteen male rabbits underwent partial tracheal defect. A full-thickness anterior defect was created in
the cervical trachea and the defect was reconstructed with
APM. Rabbits were euthanized 1, 4 and 12 weeks postoperatively, and endoscopic, histologic, and radiologic evaluations
were conducted.
Results:
All animals survived until the scheduled time. Endoscopic
evaluation revealed mild degree of lumen narrowing without
tissue ingrowth into the tracheal lumen or distal accumulation of secretions. APM was well incorporated into the surrounding tissue on histologic evaluation. Histologic exam
showed well incorporated APM into the surrounding tissue
with neovascularization. CT scan showed well maintained airway without definite evidence of chondrogenesis.
Conclusion:
Off-the-shelf use of APM for tracheal reconstruction seems to
be a promising strategy in the treatment of tracheal defects.
Grant sponsor: Basic Science Research Program through the
National Research Foundation of Korea (NRF) funded by the
Ministry of Education, Science and Technology (NRF-20110014024).
375
Oral Presentation
E-O3-3
E-O3-4
Systematic evaluation of esophageal motility and pH
in patients with laryngo-tracheal stenosis: A preliminary study
An analysis of secondary esophageal reconstruction
Dept. Cardiopneumology, Division of Thoracic Surgery, InCor
(Heart Institute)-HCFMUSP, University of Sao Paulo School of
Medicine, Brazil1), Department of Gastroenterology, Discipline
of Surgery of the Digestive Tract, Esophageal Function Laboratory, Hospital das Clinicas, Faculty of Medicine of the University of Sao Paulo, Brazil2), Department of Gastroenterology,
Discipline of Surgery of the Digestive Tract, Hospital das
Clinicas, Faculty of Medicine of the University of Sao Paulo,
Brazil3)
Paulo F.G. Cardoso1), Ary Nasi2), Angela Falcao2),
Helio Minamoto1), Sergio Szacnowicz3),
Anna C.B. Dantas3), Rubens Sallum3),
Paulo M.P. Fernandes1), Ivan Cecconello3)
Background: Laryngo-tracheal stenosis poses a major management
problem that requires multiple surgical!endoscopic procedures for
its correction. We have observed an increasing number of recalcitrant stenoses and late post-operative recurrences that led us to investigate other causes that may impact on the outcome. Gastroesophageal reflux (GER) is known to affect wound healing both in the
larynx and the trachea. This study focused on a systematic assessment of esophageal motility and pH in patients presenting with high
airway stenosis in order to assess the prevalence of pathologic GER
in this patient population. Methods: patients 18 years and older with
idiopathic, post-intubation stenosis or with recurrence of the stenosis
following laryngo-tracheal resections were included. Exclusion criteria were advanced age, previous anti-reflux surgery, esophagectomy
and!or gastrectomy. Patients were submitted to stationary manometry using an eight-channel perfused catheter connected to a
low compliance pneumohydraulic pump (Multiplex II, Alacer Biomedica, Brazil). The assessment included lower esophageal sphyncter (LES) position and pressure, motility and pressures of the esophageal body and upper esophageal sphyncter pressure. The 24-hour
pH study used a dual channel antimony electrode catheter and a logger (AL-3, Alacer Biomedica, Brazil). Results: 80 patients (50 males)
with 44+16 years of age were assessed. Twenty nine patients (36%)
presented with typical GER symptoms. Esophageal manometry revealed normal LES pressure (21,3 9mmHg; normal=14mmHg-34
mmHg) and 24,6% presented with a hypotonic LES. The distal
esophageal body average pressure was normal (100mmHg) with only
10,9% of the cases with hypomotility (less than 30mmHg). Esophageal pH study was performed in 74 patients and 50% showed abnormal acid reflux exposure in the distal electrode with an average of
5,2% of total monitoring time (normal less than 4,5%) and a DeMeester score of 21,2 (normal less than 14,7). There was a predominance of supine GER (4,3%; normal less than 3,5%). Thirty patients
(40,5%) presented with supraesophageal acid reflux as detected by
the proximal esophageal pH electrode (average of 1,2 episodes!patient). Conclusion: This preliminary study in patients with laryngotracheal stenosis reveals a high prevalence of abnormal acid reflux
predominantly in supine position, and with prevalent upper esophageal acid exposure. This occurred in a setting of low incidence of
typical GER symptoms and in the presence of normal esophageal
motility in the majority of the patients. A larger study is being designed to investigate the role of acid and non-acid reflux in a larger
cohort of patients with upper airway stenoses.
376
Department of Plastic and Reconstructive Surgery, Dokkyo
Medical University, Japan
Norio Fukuda, Hirotaka Asato, Yasutoshi Suzuki,
Kouhei Umekawa, Masaya Imanishi, Takeshi Kan
Background
We sometimes experience tissue necrosis after esophageal
reconstruction. If esophageal reconstruction is failed, patient s quality of life is severely decreased. We analyze the
cases with esophageal defects after failure of immediate reconstruction and discuss the details of secondary reconstruction.
Methods
Between April 2006 and October 2013, we treated 10 patients who required secondary reconstruction of esophageal
defects after immediate reconstruction of esophagus. Of
these 10 patients, the first immediate reconstruction of the
esophagus had been performed with digestive tract pull-up
(no additional microvascular anastomosis) in 6 patients, and
with free jejunum transfer in 4 patients. We investigate retrospectively the selection of reconstructive option required
in each case.
Results
We performed free jejunal transfer (including patch-typed
transfer) as first choice. If free jejunal transfer cannot be
used, colonicinterposition or jejunal pull-up were performed.
In cases of additional skin necrosis of neck, the coverage by
DP flap was also required. If infection invaded cervical major
vessels, pedicled skin flap transfer was needed over the vessels as a re-operation and esophageal reconstruction was
planned secondary after infection was controlled.
Conclusion
There are several surgical choices about secondary operation of failed esophageal reconstruction but the tissue transfer according to the necrotic region is needed. Necrosis of reconstructed esophagus occurs mainly because of insufficiency of the blood supply. To prevent such complication additional microvascular anastmous is important in case of digestive tract pull-up, and frequent check of blood supply using Doppler device or monitoring flap in case of free jejunum
transfer.
Oral Presentation
E-O3-5
E-O4-1
Endoscopic treatment of recurrent te fistula by KTP laser cauterization with tissue fibrin glue adhesion in
children
Efficacy of type 3 thyroplasty as pitch-lowering surgery in patients with a high-pitched voice
Department of Otolaryngology, National Taiwan University
Hospital, Taiwan1), Department of Pediatrics, National Taiwan
University Hospital, Taipei, Taiwan2), Department of Surgery,
National Taiwan University Hospital, Taipei, Taiwan3), Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan4)
Wei-Chung Hsu1), Chia-Fong Wu2), Wen-Ming Hsu3),
Steven Shinn-Forng Peng4)
Background:
Congenital tracheoesophageal fistula (TEF) in children remains the most common congenital anomaly of the esophagus. Although it is a relatively rare condition, this complex
anomaly is still a challenging problem in pediatric surgery,
especially when recurrent fistula was noted after primary
repair. Revised open surgery with a second thoracotomy is
technically difficult and always complicated with comorbidity. Therefore, the aim of this study was to investigate the value of endoscopic approach by potassium-titanylphosphate (KTP) laser cauterization with tissue fibrin glue
adhesion in the treatment of recurrent congenital tracheoesophageal fistula (TEF) after primary repair in children.
Methods:
This study enrolled 4 children with recurrent TEF in a tertiary referral medical center. All of them received endoscopic
approach to identify the presence of recurrent fistula, following by KTP laser cauterization with tissue fibrin glue adhesion.
Results:
All the children had successful endoscopic repair of their recurrent fistula by 1-3 procedures with no residual fistula
noted by barium esophagogram. Clinical symptoms of coughing, choking after feeding, and episodes of aspiration pneumonia were subsided. One case received fundoplication to
treat associated severe gastroesophageal diseases (GERD)
and another case needed repeated endoscopic dilatation for
the esophageal stricture due to previous primary esophageal
reconstruction surgery.
Conclusion:
Endoscopic approach with KTP laser cauterization and tissue fibrin glue adhesion is a valuable option to treat recurrent congenital fistula in children. Utility of KTP laser to create raw mucosal surface then sealing the fistula by tissue fibrin glue is the mainstay of endoscopic repair. It is an effective and safe alternative to re-open surgical repair, which
might be applied repeatedly without obvious major complications.
Head & Neck Surgery, Tokyo Medical University Hachioji
Medical Center, Japan1), Isshiki Clinic Kyoto Voice Surgical
Center2), San-no Hospital International University of Health
and Welfare, Tokyo Voice Center, Tokyo3), Tokyo Medical
University, Dept. of Otorhinolaryngology, Tokyo4)
Kazuhiro Nakamura1), Kiyoaki Tsukahara1),
Nobuhiko Isshiki2), Masahiro Tanabe2),
Yusuke Watanabe3), Daigo Komazawa3), Mamoru Suzuki4)
Type 3 thyroplasty (TP3) is a surgical technique for reducing
the anteroposterior diameter of the thyroid cartilage. The
operation results in relaxation of the vocal folds, a low speaking fundamental frequency (SFF), and improvement of the
laryngeal efficiency. The major indications include patients
with a high SFF associated with vocal fold atrophy or mutational voice disorder, and sulcus vocalis, who show unsatisfactory response to voice therapy. In this study, we assessed
the pre- and post-surgical voice, laryngeal efficiency, and surgical technique in patients who underwent TP3, using sound
and movie files. The subjects were 30 patients who had undergone TP3 as pitch-lowering surgery at our institution.
The period during which this surgery was performed was
divided into the first period (2001 to 2006), in which 19 patients were treated at the Isshiki Clinic Kyoto Voice Surgical
Center (IC group), and a second period (2007 to 2013), in
which 11 patients were treated at the Tokyo Medical University Hachioji Medical Center and subsidiary hospitals
(TMU group). We comparatively evaluated the results in the
2 groups. In all cases, TP3 had been performed under local
anesthesia or total intravenous anesthesia. With TP3, the
tension of the vocal folds decreased, and the voice became
low-pitched. The pre- and post-surgical SFF were measured
in all subjects, and the aerodynamic indices (AC!
DC ratio,
mean flow rate, and maximum phonation time) were calculated. The SFF decreased in all 30 patients. In the IC group,
the mean preoperative SFF was 197.2 Hz, which decreased
to a mean of 138.0 Hz postoperatively. In the TMU group, the
mean preoperative SFF was 198.5 Hz, which decreased to a
mean of 114.9 Hz postoperatively. Thus, there were no significant differences in the results between the two groups.
TP3 was useful as a surgical treatment to lower the pitch
and yielded results that the patients were satisfied with. It
was also effective in improving the laryngeal efficiency, since
most subjects showed improvement of the aerodynamic indices.
377
Oral Presentation
E-O4-2
E-O4-3
Effects of type II thyroplasty for adductor spasmodic
dysphonia
Dimensions and morphological characteristics of human newborn glottis
Department of Otolaryngology-Head and Neck Surgery, Hokkaido University School of Medicine, Japan1), Department of
Otolaryngology-Head and Neck Surgery, Yokohama City University School of Medicine, Japan2), Department of Communication Disorders, Health Sciences University of Hokkaido, Japan3)
Kenji Mizoguchi1), Hiromitsu Hatakeyama1),
Nobuhiko Oridate2), Noriko Nishizawa3), Satoshi Fukuda1)
Background
Adductor Spasmodic Dysphonia (AdSD) makes various voice
problems such as vocal strangulation, tremor and interruption.
Type II thyroplasty is based on the hypothesis that the voice
symptoms in AdSD are a consequence of excessively tight
glottal closure. This surgery reduces the excessive tight closure of the vocal folds during the phonation by cut and
spread the midline of the thyroid cartilage.
Type II thyroplasty has several advantages as below. First,
the effect is stable. Second, intraoperative adjustment is possible. Third, no direct surgical intervention into vocal folds is
required. Finally, the procedure is reversible and readjustable.
Objective
To report the short-term outcome of type II thyroplasty in
the treatment of AdSD.
Methods
Retrospective, case-control study, single institution.
Patients
15 patients underwent type II thyroplasty from March 2012
to Octorber 2013. The average patients age was 28 years,
symptom duration was 47 months, VHI-10 was 25.7.
Surgery
All 15 cases were performed under local anesthesia. First,
the midline of the thyroid cartilage is vertically incised, and
the incised cartilages are spread and fixed by two titanium
bridges. The average operative duration was 90 minutes.
Results
Mean follow-up period was 12 months. There was no significant complication. The average VHI-10 after one, three, six
and 12 months after surgery were 9.2, 7.9, 10.0 and 6.8 respectively. All patients feel easy to phonate two or three
weeks after the surgery.
Conclusion
Type II thyroplasty significantly improved VHI-10 soon after
the surgery. Through we must keep studying to report the
long-term effect, we think this surgery can be a first choice
of AdSD.
378
Department of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, Japan
Kiminori Sato, Shun-ichi Chitose, Hirohito Umeno,
Tadashi Nakashima
Background: The glottis consists of two pars: the intermembranous portion (anterior glottis) and intercartilaginous portion (posterior glottis). The border of the two is defined by a
line between the tips of the bilateral vocal processes. The anterior glottis plays the most important role for phonation. On
the other hand, the posterior glottis appears to play an
equally important role in respiration.
There have been numerous investigations of the anatomy
and physiology of the anterior glottis. In contrast, the posterior glottis, especially the newborn posterior glottis has been
studied little.
Dimensions and morphological characteristics of the human
newborn glottis were investigated.
Methods: A total of 16 larynges obtained from autopsy cases
were used. Six were male and ten were female. All of them
were from mature newborns. The whole organ section technique was employed. The specimens were fixed in 10% formalin, dehydrated in graded concentrations of ethanol, and
embedded in paraffin. Horizontal sections, which were parallel to the membranous portion of the vocal folds, were made.
Hematoxylin-eosin and elastica-van Gieson stains were employed for each section, and then morphological characteristics of the human newborn glottis were observed using light
microscopy. Dimensions of the newborn glottis were measured with computer software (ImageJ, NIH, USA).
Results: The average length of the glottis was 5.4 0.6 (average SD) mm in males and 5.7 0.4 mm in females. The average length of the posterior glottis was 3.1 0.5 mm in males
and 3.2 0.4 mm in females. It accounted for 57.5 3.2% of the
entire glottic length in males and 55.5 5.3% in females. The
absolute values of the length and ratio did not differ significantly between the two sexes.
The average area of the glottis was 7.5 2.5 mm2 in males
and 8.2 1.7 mm2 in females. The average area of the posterior glottis was 5.3 2.0 mm2 in males and 5.5 1.4 mm2 in females. It accounted for 69.2 4.6% of the entire glottic area in
males and 67.3 5.8% in females. It also accounted for 68.0
5.3% of the entire glottic area in both sex. The absolute values of the area and ratio did not differ significantly between
the two sexes.
The epithelium in the newborn posterior glottis was a respiratory epithelium (ciliated epithelium), whereas it was stratified squamous epithelium in the anterior glottis.
Conclusions: The newborn posterior glottis occupied approximately 70% of the entire glottic area, and was covered
with respiratory epithelium. The newborn glottis is favored
not for phonation but for respiration.
Oral Presentation
E-O4-4
E-O5-1
Modulation of MyoD-positive satellite cells and myocytes following recurrent laryngeal nerve regeneration
Electrical stimulation induces adduction of immobilized vocal fold with unilaterally paralyzed larynx
Department of otolaryngology, head and neck surgery, Kumamoto University, Japan
Department of Otolaryngology Head and Neck Surgery, Asahikawa Medical University, Japan
Haruka Kodama, Yoshihiko Kumai, Kohei Nishimoto,
Eiji Yumoto
Akihiro Katada, Ken-ichiro Nomura, Isamu Kunibe,
Yasuaki Harabuchi
Background!
Hypotheis; Satellite cells (SCs) in skeletal muscle are activated after various muscle injuries and denervation. These cells are the primary stem cells in adult skeletal
muscle and are responsible for muscle regeneration. Denervation has been reported to induce the activation and proliferation of SCs in the limb muscles of the rat, and MyoD, a
myogenic regulatory factor, is expressed in activated and
proliferating SCs and myocytes(MCs).We hypothesized that
these MyoD positive SCs and MCs might contribute to the
regeneration of muscle fibers following reinnervation.
Objective; To examine the modulation of MyoD+SCs and
MyoD+MCs following recurrent laryngeal nerve reinnervation and to elucidate the correlation between these processes
and establishment of neuromuscular junctions (NMJs) in the
reinnervated rat thyroarytenod (TA) muscle.
Methods: Seventy six eight-week Wistar rats were divided
into three groups, I) denervation alone (DNV) (n=32), II)denervation and immidiate anasotmosis (ANS) (n=32) and III)
sham as control (n=12). The left recurrent laryngeal nerve
(RLN) was transected in both DNV and ANS groups, and in
the ANS group, end-to-end anastomosis was performed immediately after the transection. Animals in both groups
were sacrificed at 3 days, 1 week, 3weeks and 5 weeks after
the treatment. Fluorescein immunostaining was used to visualize the localization of MyoD+SCs and MyoD+MCs in combination with M-cadherin, immunostaining, a marker for SCs
in the TA muscle. We also quantitatively examined the temporal changes of MyoD and M-cadherin expression, with real
time-PCR. Moreover, Anti-neurofilament, anti-synaptophysin
antibodies and α-Bungarotoxin were used to detect and
quantitatively evaluate the process of NMJs formation in the
TA muscle.
Results; Real-time PCR demonstrated the up-regulation of
both MyoD and M-cadherin in the treated side of the TA
muscle at early time points (<1week) and down-regulation at
later time points (>3weeks) in both DNV and ANS. However,
MyoD expression had been significantly higher (P<0.05) than
that of control in all experimental time points in only DNV.
Moreover, MyoD was significantly (p<0.05) less expressed at
5weeks and M-cadherin was (p<0.05) less expressed at 3
weeks in ANS in comparison with DNV. Immunohistochemical qualitative analysis supported these results. In addition,
NMJs formation was detected only in ANS and the ratio for
numbers of nerve terminal!
those of acetylcholine receptor
gradually increased time dependently later than 3 weeks.
Conclusion; Contrary to our hypothesis, these data suggested that NMJ formation following RLN reinnervation
might result in eactivation of MyoD+SCs and MyoD+MCs
for normal TA muscle regeneration.
Objectives
The final goal of our research is clinical application of functional electrical stimulation (FES) to restore laryngeal motor
function of the patients with vocal fold paralysis. The first
purpose of this study was to create a new implantable electrode to stimulate paralyzed laryngeal adductor muscle for
long period. The second purpose is to confirm the feasibility
of FES to adduct the immobilized vocal fold in chronic animal
model.
Materials and Methods
Four canines were used in this study. To clarify the influence of reinnervation to the efficacy of FES, the animals divided into reinnervated and denervated groups. In reinnervated group, right recurrent laryngeal nerve was sectioned
and repaired immediately. In denervated group, right recurrent laryngeal nerve was sectioned and not repaired. An
electrode array consisted of 8 active platinum disk electrodes, mounted on a 10 8 1 mm silicone plate. This electrode array was placed between the thyroid cartilage and
thyroarytenoid muscle. Vocal fold angle from anterior commissure to vocal process was measured endoscopically in the
anesthetized animal. Each endoscopic session with a chronic
animal model was conducted four months after the nerve
section.
Results
In reinnervated group, FES induced optimal glottal closure
with low current. Vocal fold easily adducted to the midline.
Even in denervated group, FES could induce vocal fold adduction. But induced adduction was very small, and high current was required to move the vocal fold.
Long-lasting muscle contraction should induce muscle fatigue. And it is easily speculated that fatiguing contraction
decrease vocal fold adduction during continuous electrical
stimulation. To confirm the decrease of adduction during
continuous electrical stimulation, paralyzed laryngeal adductor muscle was stimulated during 3 minutes continuously.
The vocal fold gradually moved from the medial to the lateral by 3 minutes continuous stimulation, but adduction of
paralyzed vocal fold have sustained and positioned over the
midline until 2 minutes.
Conclusions
This study demonstrated that paralyzed adductor muscle
stimulation with new shaped electrodes could produce optimal glottal closure. Reinnervation of paralyzed muscle was
more preferable to induce adequate adduction of vocal fold.
Induced vocal fold adduction by FES was long enough to improve voice sounds in case of unilateral vocal fold paralysis.
379
Oral Presentation
E-O5-2
E-O5-3
Regeneration of vocal fold mucosa using a tissueengineered structure containing oral mucosal cells
Evaluation of voice function using newly developed
two maps considered by vocalization components
Department of Otolaryngology Head and Neck Surgery, Kurume University School of Medicine, Japan
Department of ENT, Voice Tec Vocal Art Science Laboratory,
Japan
Mioko Fukahori, Shun-ichi Chitose, Kiminori Sato,
Shintaro Sueyoshi, Takashi Kurita, Hirohito Umeno,
Tadashi Nakashima
Haruhito Saida
Background: Viscoelastic properties of vocal fold mucosa are
very important for vocal fold vibration.Scarred vocal fold or
sulcus vocalisresult in irregular vibration during phonation
due to the stiffness of the vocal fold mucosa. Several approaches for these diseases have been reported, including
the use of injection laryngoplasty. However, a completely
satisfactory procedure has not yet been achieved. We hypothesize that a potential treatment option for these diseasesis to replace the vocal fold mucosa with a tissueengineered structure containing autologous cells.
Objectives: The aim of this study is toregenerate vocal fold
mucosa using a tissue-engineered structure containing autologous oral mucosal cells.
Methods: A 3-by-3-mm specimen of canine oral mucosa was
surgically excised under general anesthesia. It was divided
into epithelial and subepithelial tissues. After pure epithelium was collected by removing all epithelial layers, epithelial
cells were isolated and cultured using cell-culture inserts (BD
Falcon) with 3T3 feeder layers for 2 weeks. Simultaneously,
fibroblasts were isolated from the subepithelial tissues and
cultured using a direct explant technique for 2 weeks. The
proliferated epithelial cells were seeded and co-cultured on
the oriented collagen gels containing the proliferated fibroblasts. After an additional 2-week co-cultured period, the organotypiccultured tissue was transplanted to the mucosadefected vocal fold. Seven weeks after the transplantation,
the larynxwas removed. The vocal fold vibration and morphological characteristics were observed using the removed
larynx.
Results: We successfully fabricated a tissue-engineered vocal
fold mucosawith epithelium and lamina propriaclosely resembling the normal vocal fold layers. The epithelium had
two to three cell layers and do not resemble the original oral
mucosa. The epithelial cells were immunostained with anticytokeratin antibodies, anti-b1 integrin antibodies. The fibroblasts in the collagen gels were immunostained with antivimentin antibodies. Regarding the removed larynx, laryngeal stroboscopy revealed that the mucosal wave at the
transplanted lesion is regular but slightly small. Histological
findings showed the lamina propria with less elastic fiber
covered with stratified squamous epithelium. All epithelial
layers expressed cytokeratin and E-cadherin. The scattered
cells in the lamina propria expressed vimentin.
Conclusion: The organotypic mucosa fabricated from autologous oral mucosal cells successfully restored the vocal fold
mucosa.To obtain the optimal viscoelasticity of vocal fold,
further adjustments of the fibrous density in the lamina
propria is needed.
380
It is often the case that voice users do not show any noticeable vocal
problem during ordinary voice evaluations at ENT clinic, mainly because
those tests are usually performed to evaluate simple and easy phonation.
In general, however, voice users use their voice in more effortful conditions. Further, voice users present a variety of vocalizations, and therefore, there is no single way in their vocalization. Thus, more appropriate
methods should be necessary for evaluating their voice. As a preliminary
approach to objective assessment of vocalization method, I developed
two maps, named Voice-Maps, based on the concept that the regulation
of voice is effected by cooperative controls of expiratory, laryngeal and
vocal tract components.
Method
The present paper proposed the use of 2 types Voice-Maps for the assessment of vocal regulation.
The first Voice-Map is Voice-Map E-L (E:Expiratory control, L:Laryngeal control) comparing the flow rate during phonation as an indication
of the expiratory function with voice pitch as an indication of the pattern
of the laryngeal control. The horizontal axis represents the voice pitch,
while the vertical axis represents the flow rate measured by the fonomater.
In this map, the relationship between the voice range and the flow rate is
expressed. It is also possible to indicate the classification of vocal cord vibration patterns in this map.
The second is Voice-Map L-V(V:Vocal tract configuration), comparing
the estimated vocal tract configuration with the laryngeal control in
term of degree of glottal closure estimated by Electroglottography
(EGG). The horizontal axis represents vocal tract configuration, while the
vertical axis represents the laryngeal control. In the vertical axis, the
weaker glottal closure is shown upward. Therefore, the more strained
voice is shown in the lower region, while the breathy phonation is represented in the upper region. In the horizontal axis, the longer vocal tract
is a negative side, the shorter is a positive side.
Results and Conclusion
It was found that the vocalization method is effectively expressed by using Voice Map E-L and Voice Map L-V. It was also suggested that the
control of vocalization to create various patterns of voice could be designed by the use of the 2 maps. Thus, the use of these 2 maps appeared
to be effective for an objective evaluation of vocal abilities of voice users.
Oral Presentation
E-O5-4
E-O5-5
A case report of bamboo node associated with systemic lupus erythematous
Airway management of midline fixation of the bilateral
vocal folds
Otolaryngology, Head and Neck Surgery, Japanese Red Cross
Ashikaga Hospital, Japan
Department of Otolaryngology, Head and Neck Surgery, Kumamoto University Graduate School of Medical Science, Japan
Nobuharu Matsumoto, Daisuke Baba,
Takehiro Tominaga, Shun-ichi Sasaki
Masako Masuda, Eiji Yumoto
Vocal fold bamboo nodes is a unique laryngeal lesion in patients with autoimmune disease, such as Systemic lupus
erythematous (SLE). There are few studies on laryngeal involvement in SLE called lupus laryngitis. In most previously
reported cases, the lesion in vocal folds was found after diagnosis of autoimmune disease. We report here a case of lupus
laryngitis, which was promptly suspected by the observation
of a unique lesion in the vocal fold.
In April 2013, a 19-year-old woman who had not had a diagnosis of systemic disease had a sudden onset of hoarseness.
She consulted an otolaryngologist, who suspected a submucosal vocal fold cyst or bacterial infection, and received antibiotics, which did not improve her voice quality. In August
2013, she was reffered to our hospital for removal of the lesion under laryngomicrosurgery. The unique feature of bamboo nodes in the vocal fold led us to suspect autoimmune disease. The preoperative blood examination had revealed antinuclear and anti-Sm antibodies. In September 2013, She was
diagnosed as having SLE based on findings of malar rash,
lymphocytopenia, renal dysfunction, hypocomplementemia,
positive anti-nuclear and anti-Sm antibodies.
She was treated with 60mg of prednisolone which resulted in
improvement of hoarseness. Based on these findings, we diagnosed her hoarseness as the manifestation of laryngitis associated with SLE. After all, she did not undergo an unnecessary operation.
When a bamboo node lesion of the vocal fold is found by otolaryngologist, an associate autoimmune disease must be assumed. Then it is necessary to initiate appropriate diagnostic
procedures promptly.
Background;
Midline fixation of the bilateral vocal folds (bilateral fixation) may cause
dyspnea, hoarseness, and dysphagia. Especially in cases of life-threatening
respiratory distress, emergency intervention is required. We conducted a
retrospective study of bilateral fixation patients, focusing on respiratory distress and airway management.
Methods;
65 patients were diagnosed with the bilateral fixation in Kumamoto University Hospital from January 2002 to March 2013. 36 men and 29 women, and
the mean age at diagnosis was 64.2 years (range, 35-85 years). We retrospectively assessed the causes of bilateral fixation, symptoms, prognosis, airway
management and outcome of the surgery for airway widening.
Results;
Results of airway management are shown in Table. Unilateral or bilateral
movement of the vocal fold was recovered in 21 patients (32.8%) during the
follow up period. All of them recovered within four months from the onset. 9
patients showed slightly or intermittent dyspnea, and they didn t hope the
surgical treatment. 6 patients were in severe general condition, so we couldn t follow up.
Airway widening surgery was performed in 14 patients. Laterofixsation of
unilateral vocal fold (Ejnell s operation) was done for 13 of them. 9 of them
had no subjective dyspnea at the onset of bilateral fixation, but respiratory
symptom was gradually appeared several years after the onset. Laterofixation of the vocal fold by extralaryngeal approach (Woodman s operation) was
performed in one patient. All 14 patients were free of tracheostoma after the
surgery, and nobody showed postoperative dysphagia and severe hoarseness.
15 patients were performed tracheostomy and their tracheostomas did not
closed. All of them had an incurable disease such as malignant tumor.
Conclusions;
Tracheostomy or airway widening surgery does not necessarily required
because some patients are free of dyspnea for incomplete paralysis or sufficient glottic space for breathing. However, in some cases, respiratory distress gradually arises several years after the onset of bilateral fixation. We
have to pay attention that there is a tendency for fixed position of the bilateral vocal folds to be gradually adducted.
Ejnell s operation is the most simple and minimum invasive method in various airway widening surgery, and showed good results in our data. However, unilateral or bilateral movement of the vocal fold was recovered in
one-third of patients within four months after the onset. Decision of airway
widening surgery should be made at least six months after the onset of vocal fold fixation.
381
Oral Presentation
E-O6-1
E-O6-2
Can mano-videoendoscopy substitute for videofluorography in evaluation of upper esophageal
sphincter function?
Dysphagia problems after chemoradiation theraphy in
nasopharyngeal carcinoma patients
Department of Otolaryngology, Kyorin University, School of
Medicine, Japan1), Department of Oral and Maxillofacial Surgery!
National Defense Medical College, Japan2), Japan Welfare
Education College, Japan3)
Takehiro Karaho1), Tetsuya Satoh1), Junko Nakajima2),
Takeshi Nakayama3), Naoyuki Kohno1)
Objectives: Fiberoptic endoscopic evaluation of swallowing
(FEES) is one of the standard procedures to examine the
swallowing function. Compared with videofluorographic
swallowing study (VFSS), FEES has the disadvantage of not
allowing visualization of the esophageal stage of swallowing.
The information about the upper esophageal sphincter (UES)
function is very important for the subsequent treatment
strategy. Manovideoendoscopy (MVE) is the manometry techinique with endoscopically confirming the pressure catheter without radiation exposure. The objective of this study
was to investigate the possibility of replacing videofluorography with MVE as a test to evaluate the function of the UES.
Study Design: Retrospective study of 45 patients with
dysphagia.
Methods: All patients were underwent both MVE and VFSS
for evaluation of dysphagia. Informed consent was obtained
on all subjects in the study. The manometry was performed
with nasally inserted catheter, OD 2.6mm with 4 pressure
sensors. The sensors were kept at tongue base, upper pyriform sinus, apex of pyriform sinus, and UES. The endoscopic
view of the pharynx and the pressure waveforms were recorded in the computer simultaneously. We performed comparisons between the manometric findings of UES relaxation
and fluoroscopic UES opening.
Results: The pressure-drop in the UES and the UES relaxation time had significant correlation on the fluorographic
UES opening finding.
Conclusion: By performing manometry in addition to standard FEES techniques, it is possible to supplement functional evaluations of UES function, thus overcoming the
drawback of FEES.
382
Otorhinolaryngology, Indonesia University School of Medicine, Indonesia
Susyana Zainuddin Tamin, Arfan Noer, Marlinda Adham
Background: 1.Able to elicit dysphagia problem in Nasopharyngeal Carcinoma patients that underwent chemoradiation
therapy 2.To evaluate the potential risk of aspiration.
Methods: This study was done from January to April 2010 in
39 Nasopharyngeal Carcinoma patients after Chemoradiation therapy from ENT Department, Faculty of Medicine, Indonesia University, Dr.Cipto Mangunkusumo Hospital Jakarta, Indonesia. Patient s history and symptoms and the
Flexible Endoscopy Evaluation of Swallowing examination
(FEES) were done to evaluate the swallowing function of the
patients. Five criteria of difficulty in swallowing such as
preswallowing leakage, sensitivity, residue, penetration and
aspiration were observed.
Results: Of the 39 samples, most is male patients with the
largest age group was >40 years (64.1%), the youngest is 16
years old and the oldest is 64 years. The number of samples
with advanced stage (III-IV) was found in the highest percentage of 84.6 percent. As muchas 51.3% Chemotherapy is
given concurrently with radiation. Cisplatin, 5 Fluorourasil
are the most common drugs given. Furthermore, 51.3% received radiation doses greater than 70 Gy.
The most common findings in the oral phase of dysphagia
are dry mouth(92.3%), loss of appetite(43.8%), however, choking and lump in the throat as the findings of the pharyngeal
phase were equally noted.
Preswallowing assessment was conducted to evaluate structures involved in the swallowing process, it revealed epiglottis edema in upright position was 89.4%, the presence of poor
oral hygiene and velopharyngeal closure weakness during
swallowing (56.4%). Other abnormalities i.e. tongue fasciculation, buccal muscle weakness, asymmetry movement of the
soft palate, poor cough reflex and the absence of swallowing
movements were found in smaller percentages. Standing secretion with mild degree were found in 38.5% and severe degree in 30.8% and 35.9% showed penetration of secretions,
and 10.3% revealed aspiration of secretions, however no
presence of silent aspiration there.
After having tested with difference consistencies of food,
residue were found nearly in all samples and penetration in
40.5% and the presence of aspiration happened only in 3 samples with 1 sample with silent aspiration. There was a statistically significant difference in the severe degree of residual
of puree, solid food and thick liquid before and after the administration of thin liquid (p<0.001).
Conclusions: This study obtained the changing of hypopharyngeal structure with the presence of the edema of epiglottis in upright position eliminate the presence of aspiration of
food to the airways.
Keywords: dysphagia, nasopharyngeal carcinoma, chemoradiation, aspiration
Oral Presentation
E-O6-3
E-O6-4
Laryngotracheal separation for type III laryngotracheoesophageal cleft with type C esophageal atresia
Postdeglutive residue in associated unilateral laryngeal paralysis vs recurrent laryngeal paralysis
Department of Otorhinolaryngology, Asanogawa General Hospital, Japan1), Department of Pediatric Surgery, Kanazawa
Medical University2), Department of Head and Neck Surgery,
Kanazawa Medical University3)
Toru Miyazawa1), Yoshitomo Yasui2), Yuzo Shimode3),
Miyuki Kohno2), Hiroyuki Tsuji3)
Laryngotracheoesophageal cleft (LTEC) is rare congenital malformation in which
a cleft exists in the tracheoesophageal septum. LTEC tend to occur various other
malformations such as esophageal atresia, heart malformations. Although several
cleft-closing techniques have been reported, the prognosis can be very poor especially on the high grade LTEC with multiple malformations.
We experienced a female neonate with type III LTEC accompanied with type C
esophageal atresia, duodenal atresia and congenital heart disease diagnosed as a
double outlet right ventricle(DORV).
She underwent repair of the duodenal atresia and establishment of a gastrostomy
at the age of 0 days, then be fed via the gastrostomy. However, severe pneumonia
developed at 3 months of age because of reflux from the stomach via the tracheoesophageal fistula. To prevent this reflux, a tracheoesophageal fistulectomy
was performed at 4 months of age. At the age of 11 months, a tracheostomy was
established to remove secretions from the airway, however, aspiration of saliva
into the respiratory tract resulted in a severe asthma attack. We planned to perform laryngotracheoesophagoplasty, which provides laryngeal function, but this
was precluded by difficulties controlling her asthma and need to perform surgery
for the DORV as early as possible to ensure long-term survival. After careful consideration, we performed laryngotracheal separation at 1 year 7 months of age
and established an end-tracheostomy to completely and immediately prevent aspiration. The upper esophagus pouch and almost the whole length of the trachea
were sufficiently exposed via a cervical approach with the neck in an extended
position without a sternotomy. We also interpose the sternohyoid and sternothyroid muscles between the separated trachea and esophagus, preventing fistula
reformation after laryngotracheal separation.
The patient was quite well postoperatively. The asthma attack ceased immediately, and radical surgery for the DORV was performed at the age of 2 years 2
months. Oral cavity secretions are currently expelled from the mouth and nose
because the oral side of the esophagus still has a blind end, but she is in excellent
general condition and does not require oxygen administration at 2 years 10
months of age.
Ideally, the surgical repair for LTEC should be laryngotracheoesophagoplasty to
obtain function of the larynx. However, this procedure might be difficult depending on the severity of the LTEC and the accompanying malformations. We believe that our procedure is a feasible choice for long-term survival in patients with
a severe LTEC with congenital heart disease.
Department of Otolaryngology Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Japan
Yoshihiko Kumai, Yasuhiro Samejima, Eiji Yumoto
Background!
Hypothesis:Unilateral vocal fold paralysis with
lower cranial nerve paralysis is categorized as associated
unilateral laryngeal paralysis (AULP). This is presented by
multiple etiologies, including malignancy, surgical iatrogenic
injury, and non-surgical trauma. It is clinically well known,
that AULP patients might suffer from much severe swallowing dysfunction in comparison with isolated recurrent laryngeal nerve paralysis (RLNP) patients. However, clinical prognosis of differences between AULP and RLNP alone are still
controversial and further objective and quantitative analysis
would be necessary. We hypothesized that AULP patients
were more likely to demonstrate increased residue and
asymmetry in the affected pyriform sinus as compared with
RLNP patients, suggesting that high vagal nerve damage
may cause significantly increased residue in PS.
Objectives: To quantitate postdeglutitive pharyngeal residues in patients with associated unilateral laryngeal paralysis (AULP) and determine its association with high vagal
nerve paralysis.
Methods: Among forty eight unilateral AULP patients, who
were consulted to our department for swallowing dysfunction from 1998 to 2011, without any history of neck surgery,
15 patients (Group I) who were diagnosed as isolated vagus
nerve paralysis were included. The other 26 patients with
isolated recurrent laryngeal nerve paralysis (RLNP) served
as control (Group II). All subjects underwent videofluoroscopic swallow studies. Vallecula and pyriform sinus (PS) in
the anterior-posterior view were analyzed quantitatively using video editing software; Dipmotion pro 2D○R. In both regions, the symmetry of the affected versus non-affected sides
between two for both groups were statistically compared.
Results: The affected PS of group I demonstrated significantly increased residue (p<0.01) as compared with the nonaffected PS but with no significant difference with respect to
the vallecula. Same comparison for both regions demonstrated no significant difference in group II. Group I showed
significantly increased residue on the affected PS (P<0.01)
compared with those in group II but not on the affected
vallecula residue.
Conclusions: AULP patients were more likely to demonstrate increased residue and asymmetry in the affected PS
as compared with RLNP patients, suggesting that high vagal
nerve damage may cause significantly increased residue in
PS.
383
Oral Presentation
E-O7-1
E-O7-2
Advantageous effects of a novel central-part laryngectomy for intractable aspiration
Effectiveness of laryngotracheal separation in neurologically impaired pediatric patients
Department of otolaryngology & Head and Neck Surgery, Tohoku University Graduate School of Medicine, Japan
Ai Kawamoto, Yohei Honkura, Yoshitaka Takanashi,
Ken-ichi Watanabe, Yukio Katori
Background: Severe dysphagia causes intractable pneumonia
that can sometimes be life-threatening. Several procedures for
prevention of aspiration have been reported. Among them, total laryngectomy is able to make a simple pharyngeal tract.
The procedure is, however, more invasive than other forms of
surgery for prevention of aspiration, for example laryngotracheal diversions, supraglottic closure, glottic closure and cricoidectomy. We devised a novel central-part laryngectomy which
is less invasive than total laryngectomy. We introduce the merits and effects of the procedure.
Methods: We conducted retrospective clinical case reviews of
eighteen patients treated using a central-part laryngectomy. In
this procedure, a relatively small area including the glottis is
removed to separate the digestive tract from the air way. In
comparison with previous narrow field laryngectomy, the surgical area is limited to the mid part of the thyroid cartilage and
the cricoid cartilage. The lateral part of the thyroid cartilage,
the entire hypopharyngeal mucosa, strap muscles, epiglottis
and hypoid bone are preserved. The thyroid gland and superior laryngeal vessels and nerve are also not invaded.
Results: All eighteen patients were relieved of intractable aspiration without major surgical complications such as postoperative bleeding or leakage at the suture of pharyngeal mucosa. In
good accordance with cut of the cricopharyngeal muscles and
removal of the cricoid cartilage in the central-part laryngectomy, postoperative video fluoroscopy showed a simple and
wide digestive tract with smooth passages of barium. Fifteen
of eighteen patients who had hoped to resume oral food intake
became able to do. After several months, two patients needed
surgical treatment for stenosis of the tracheostoma.
Conclusions: Central-part laryngectomy is a useful surgical
procedure that is preferable to other laryngectomy methods
for treatment of intractable aspiration. From the view point of
oral food intake, central-part laryngectomy also offers considerable advantages over other laryngotracheal diversion procedures.
384
Department of Otolaryngology, Yamaguchi University Graduate School of Medicine, Japan1), Department of Otolaryngology,
Tsudumigaura Handicapped Children s Hospital, Japan2)
Hirotaka Hara1), Takeshi Hori1), Kazuma Sugahara1),
Takuo Ikeda2), Hiroshi Yamashita1)
Objectives: This study aims to evaluate the effectiveness of
laryngotracheal separation in neurologically impaired pediatric patients from the viewpoint of postoperative success of
pneumonia prevention, improvement in the respiratory condition, and postoperative success rate of home-based care.
Methods: The medical records of 21 children who underwent
laryngotracheal separation at an academic medical center
from September 2004 to March 2013 were retrospectively investigated. Pre-and postoperative data, including the frequency of pneumonia treatment, the frequency of sputum
suctioning, the respiratory condition, the nutrition method,
and the outcome after laryngotracheal separation were assessed. We also used the scoring system for patients with severe motor and intellectual disabilities, medical care dependent group (SMID-MCDG) in Japan for evaluating the usefulness of laryngotracheal separation.
Results: The frequency of pneumonia treatment and that of
suctioning decreased considerably after laryngotracheal
separation. Furthermore, the respiratory condition improved
at a rate of 63.19%. The SMID-MCDG score significantly reduced after laryngotracheal sepatarion. No significant complications were observed and two-thirds of the patients were
successfully discharged for home care after the procedure.
Conclusion: Laryngotracheal separation can prevent aspiration pneumonia, improve the respiratory condition, and offer
the possibility of home care for neurologically impaired children.
Key words: aspiration pneumonia, respiratory condition, outcome
Oral Presentation
E-O7-3
Withdrawn
385
Poster Presentation
E-P1-1
E-P1-2
Treatment results and prognostic factors for
squamous cell carcinoma of the hypopharynx treated
with chemoradiotherapy
The outcome of larynx preservasion therapy for local
advanced hypopharyugeal cancer
Department of Otorhinolaryngology, Head and Neck Surgery,
Yokohama City University School of Medicine, Japan
Takahide Taguchi, Goshi Nishimura, Masanori Komatsu,
Daisuke Sano, Ken-ichiro Yabuki, Naoko Sakuma,
Yasuhiro Arai, Masahiro Takahashi, Nobuhiko Oridate
Purpose: To review our experience with concurrent chemoradiotherapy (CCRT) for patients with advanced resectable
squamous cell carcinoma (SCC) of the hypopharynx and to
evaluate the factors affecting survival and larynx preservation.
Study design: Retrospective study
Methods and Materials: The records of 102 patients with
Stage III or IV resectable SCC of the hypopharynx treated
with CCRT between January 1998 and August 2010 were reviewed. Of the 102 patients, 62 were treated with high-dose
regimens including cisplatin, 5-fluorouracil, methotrexate,
leucovorin or docetaxel, cisplatin, and 5-fluorouracil. The remaining 40 were treated with low-dose regimens including
carboplatin and uracil-tegafur, weekly docetaxel, or S-1. Radiotherapy was delivered five days a week using a single
daily fraction of 1.8 to 2.0 Gray (Gy), to a total dose of 64.8 to
70.2 Gy. Overall survival (OS), disease-specific survival (DSS),
and DSS with larynx preservation were estimated using
Kaplan-Meier methods. The log-rank test and Cox proportional hazards regression were used to identify significant
prognostic factors for OS, DSS, and DSS with larynx preservation.
Results: The 5-year OS and DSS for all patients treated with
CCRT were 51.3% and 64.3%, respectively. The 5-year DSS
with larynx preservation was 55.5%. On multivariate analysis, the content of chemotherapy was a significant predictor
of OS and DSS for patients undergoing CCRT; N stage was a
significant prognostic factor for larynx preservation.
Conclusion: The treatment method including the indication
for CCRT may be determined by the contents of the chemotherapy and the N stages of SCC of the hypopharynx.
386
Department of Otolaryngology, Head and Neck Surgery,
Graduate School of Medicine, Kyoto University, Japan
Morimasa Kitamura, Shigeru Hirano, Ichiro Tateya,
Yo Kishimoto, Seiji Ishikawa, Mami Morita, Juichi Ito
The treatment of hypopharyngeal cancer is complex and difficult to establish the optimal treatment regimen although
the combination of surgery and radiation has become the
usual form of therapy. With the improvement of the survival
rate, good quality of life has been requested by keeping swallowing or vocal function in the treatment of hypopharyngeal
cancer.
Objective: To update therapeutic outcome of local advanced
hypopharyngeal cancer in our treatment modality.
Materials and Methods: We have treated hypopharyngeal
cancer as follows in order to preserve laryngeal function
from 2008. Chemoradiation was performed in stage I!
II. In
stage III!
IV, 1-2 courses of induction chemotherapy was
treated, and followed by surgery and!
or radiation. The complete and good partial responders in primary site went into
chemoradiation, partial responders into larynx preservation
surgery, and non-responders into total laryngopharyngectomy. Post-operative radiation or adjuvant chemotherapy
was optional. Sixty eight patients with hypopharyngeal cancer were treated at Kyoto University Hospital between 2008
and 2011. Out of them, 30 patients (27 males and 3 females)
presented with local advanced cancer (T3!
T4). Their age
ranged from 37 to 89 years old with mean age of 67.4. The
subsites of tumors were piriform sinus (PS) in 27 patients,
posterior wall (PW) in 3, and post-cricoid (PC) in 1. T stage
was T3 in 19 patients, T4 in 11. N stage was N0 in 5 cases, N1
in 4, N2a in 1, N2b in 11, N2c in 8, and N3 in 1. The histology
was squamous cell carcinoma in all patients.
Results: In treatment modality, induction chemotherapy
could be performed in 21 patients. After induction chemotherapy, chemoradiation was performed in 10 patients, larynx preservation surgery in 4, total laryngopharyngectomy
in 6. Death by induction chemotherapy occurred in 1 patient.
Induction chemotherapy could not be performed in 9 patients by aged patients, bad performance status, and synchronous malignancies. Therefore radiation or total laryngopharyngectomy were performed for them. Locoregional recurrence occurred in 6 patients. Four of 6 patients were performed by chemoradiation or radiation, and 2 patients by total laryngopharyngectomy. No locoregional recurrence occured in larynx preservation surgery. One of 6 patients in locoregional recurrence was salvaged by endoscopic laryngopharyngeal surgery, and 1patient was salvaged by total laryngopharyngectomy. The other 4 patients died on disease.
Three years larynx preservation rate were 80% in T3 and
50% in T4.
Conclusion: The high rate of organ preservation approves of
our treatment regimen for local advanced hypopharyngeal
cancer.
Poster Presentation
E-P1-3
E-P2-1
The transition of laryngeal cancer incidence rate during the last two decades in Fukui prefecture
A rare case of laryngeal adenoid cystic carcinoma represented unusual circumferential stenosis in subglottic
region
Division of Otorhinolaryngology Head and Neck Surgery, University of Fukui, Japan
Masafumi Kanno, Taiyo Morikawa, Akihiro Kojima,
Shigeharu Fujieda
The male smoking rate in Japan shows a decreasing trend
since (the) 1970s and declines from the original rate of approximately 80% to 32% by 2012. Such a change of lifestyle
can expect a positive influence on the prevalence of the malignant tumor of laryngopharynx area. In the previous reports, the incidence of laryngeal cancer in Japan is about 3
people per 100,000 population, which means that approximately 3,000 patients suffer per year in the entire country.
More than 95% of laryngeal cancer patients are smokers, it is
very high compared to the 5% of non-smokers. It is said that
the incidence of cancer is equal to that of non-smokers by 10
years smoking cessation. In this research, we investigate a
change of laryngeal cancer incidence which have close relations with the smoking. We have analyzed for relation between laryngeal cancer incidence and smoking rates.
In Fukui Prefecture, the Fukui prefectural hospital, the
Fukui-ken saiseikai hospital, the Fukui red cross hospital,
and the university of Fukui hospital are able to perform
chemoradiotherapy. We have examined about gender, age,
staging, treatment methods, and survival rates for laryngeal
cancer cases that was treated in the above four hospitals. We
examined the presence or absence of a change in laryngeal
cancer incidence in Fukui Prefecture between 20-year period 1992!
2012. This is a retrospective research.
Department of otorhinOlaryngology and Head Surgery, Dokkyo Medical University, Japan
Takashi Kashiwagi, Hiroaki Kanaya, Wataru Konno,
Itsuo Nakajima, Kazutaka Goto, Hideki Hirabayashi,
Shin-ichi Haruna
Background: Adenoid cystic carcinoma (ACC) occurs in any
head and neck site containing salivary gland tissue. In the
larynx, ACC thought to be rare and account for less than 1%
of all malignant tumors. They arise from submucosal minor
salivary glands, which have a distinct anatomical distribution
in the larynx. Review of the English literature shows approximately 40 cases reported in the past 41 years. Patients
tend to present with symptoms of long duration due to slow
growth of the ACC. The precise clinical manifestation and
behavior remain unclear because of their rarity. We herein
report a rare case of laryngeal ACC with detailed clinical
course, imaging and histopathological evaluation.
Case report: 33-years-old female patient referred to our department due to prolonged cough and hoarseness over the
past 1 year. Since circumferential stenosis was observed in
subglottic mucosa by laryngeal endoscopy, the diagnosis of
chronic subglottic laryngitis with some causes or degenerative diseases such as amyloidosis was highly suspected at
that time. Computed tomography revealed circumferential,
vague and low density lesion around arytenoid and cricoid
cartilages without enhancement. Lymphadenopathy in cercical region was not detected. After a week, the patient complained severe respiratory disorder due to progression of the
subglottic stenosis. Tracheotomy was emergently done and
laryngeal biopsy was performed to clarify that lesion. Pathological diagnosis of ACC was made accompanied with typical
cribriform pattern and the patient subsequently underwent
total laryngectomy with bilateral selective neck dissection.
The final histopathological diagnosis was ACC originated
from submucosal tissue of subglottis. Although the tumor involved thyroid gland via tracheal and cricoid cartilage, surgical margins were free for tumor and lymph node metastasis
was not detected (UICC pT4a pN0). The patient did not receive any post-operative radiation or chemotherapy. After a
half year of post-operative follow-up by positron emission tomography, the patient remains free of recurrent or metastatic diseases.
Conclusions: We encountered a rare case of subglottic laryngeal ACC, which was supposed to be a non-neoplastic, inflammatory or degenerative diseases at first clinical impression.
It is important that neoplastic diseases such as ACC should
be considered as differential diagnosis for subglottic stenosis
if the lesion would manifest respiratory symptoms of long
duration.
387
Poster Presentation
E-P2-2
E-P2-3
A rare case of glottic cancer with low-risk HPV infection
Ho:YAG laser-application to laryngeal microsurgerystudy of irradiation methods-
Department of Otolaryngology, Surugadai Nihon University
Hospital, Japan
Department of Otorhinolaryngology-Head Neck Surgery, Nihon University Surugadai Hospital, Japan
Hiroumi Matsuzaki, Kiyoshi Makiyama, Ryoji Hirai,
Tomoyuki Takane, Souhei Ishii, Hirotaka Suzuki,
Akihiro Kishino
Hiroumi Matsuzaki, Kiyoshi Makiyama, Ryoji Hirai,
Itsuhiro Kudou, Yusho Higuchi, Fusako Iikuni,
Souhei Ishii, Hirotaka Suzuki, Akihiro Kishino
Background)
Human papilloma virus (HPV) is widely known as a possible
cause of laryngeal papilloma. When HPV-DNA is detected in
laryngeal papilloma patients, low-risk HPV, such as HPV
type 6 and 11 would be identified in most cases. On the other
hand, some studies have pointed out that infection of highrisk HPV, such as HPV type 16 and 18 might be related to laryngeal cancer. Although there are several case reports
about the patients who developed laryngeal cancer derived
from laryngeal papilloma, little is available on the relationship between malignant transformation of laryngeal papilloma and HPV infection. The present work is to report a case
of laryngeal cancer with low-risk HPV infection, which might
have been transformed from laryngeal papilloma.
Case)
A 74-year-old male visited a local ENT clinic, complaining of
hoarseness. Since Laryngeal fiberscopy showed a tumor in
the right vocal cord, the tumor specimen was taken for
pathological examination. The pathological diagnosis was a
squamous papilloma in the right vocal cord. The patient was
referred to this hospital seven months later. Since the tumor
covering the anterior one third of the right vocal cord was
noted again, it was resected and ablated with a HoYAG laser.
During the procedure, the laryngeal secretion was taken
around the tumor site for HPV type screening test. The
pathological diagnosis was a mixture of squamous cell carcinoma and papillary carcinoma in situ, while the HPV type
screening test revealed infection of low-risk HPV. The patient received concurrent chemoradiotherapy followed by
the surgery since the final diagnosis was T1aN0M0 laryngeal
cancer. Pathological CR was confirmed two months after the
adjuvant therapy was completed. Neither recurrence nor
metastasis has been found for the past 9 months.
Conclusion)
We experienced a case of laryngeal cancer patient with lowrisk HPV infection, who had been previously diagnosed as laryngeal papilloma. Careful follow-up should be advised in
postoperative patients with laryngeal papilloma, even
though they appeared to be infected with low-risk HPV.
388
Background: The Holmium:Yttrium Aluminum Garnet (Ho:
YAG) laser can perform evaporation, incision and coagulation simultaneously. It enables the treatment of target tissue
only, making surgery less thermally damaging to surrounding tissue.
Objective: The Ho:YAG laser provides a different range and
depth of evaporation depending on the distance between the
laser fiber tip and the mucosa. The clinical cases are presented and the potential for treatment of laryngeal diseases
is discussed.
Methods: The laser equipment used was the Versa Pulse Select 100. A larynx model was prepared from chicken meat by
layering skin, muscle, and bone with a belt into a single mass.
The tissue composition, starting from the outermost layer,
consisted of epidermis, cutis vera, subcutaneous tissue deep
muscle tissue, and vertebra.Three ablation methods were established. In Method (1), Noncontact Irradiation, chicken
meat was vaporized at an output of 1 W (0.2 J 5 pulses!
s) at
a distance of 5 mm from the leading end of the laser fiber. In
Method (2), Contact Irradiation, the chicken meat was vaporized at an output of 5 W (1 J 5 pulses!
s) by gently pressing
the leading end of the laser fiber against the chicken meat. In
Method (3), Shooting Irradiation, the chicken meat was vaporized at an output of 5 W (1 J 5 pulses!
s) by pressing the
leading end of the laser fiber strongly against the membrane.
The irradiation time was 10 s for each method.
Results: For (1) Noncontact Irradiation, transection and degeneration of the surface layer of the epidermis in tissue of
laser-irradiated sections was observed. No rupture or degeneration of dermal muscle or the deep muscle layer was observed. The range of surface ablation was 2.5 mm in diameter and 50-100 μm deep. For (2) Contact Irradiation, tissue of
laser-irradiated sections along the epidermis to the dermal
muscle was ablated and tissue degeneration was observed
along the fringe of irradiated portions. The range of surface
ablation was 0.75 mm in diameter and 3 mm deep. For (3)
Shooting Irradiation, rupture where the laser fiber contacted
the epidermis was not confirmed, but deep muscle had ruptured and degenerated nearly to the vertebra. The ablation
depth was 17 mm.
Conclusion: Application of this technique to laryngeal surgery is expected.
Poster Presentation
E-P3-1
E-P3-2
Management of the paratracheal dissection in patients
with pyriform sinus cancer (multicenter retrospective
study)
Managements for the recurrence of early hypopharyngeal carcinoma after transoral resection
Division of Head and Neck surgery, National Cancer Center
Hospital East Chiba, Japan1), Department of Head and Neck
Surgery, Saitama Cancer Center Hospital, Japan2), Department
of Otorhinolaryngology, Osaka Medical Center for Cancer and
Cardiovascular Diseases, Japan3), Department of Head and
Neck Surgery, Aichi Cancer Center Hospital, Japan4), Division
of Head and Neck Surgery, Shizuoka Cancer Center Hospital,
Japan5), Division of Head and Neck Surgery, Miyagi Cancer
Center Hospital, Japan6), Division of Head and Neck, Cancer Institute Hospital, Japan7)
Toshifumi Tomioka1), Ryuichi Hayashi1), Beppu Takeshi2),
Fujii Takashi3), Ozawa Taijirou4), Asakage Takahiro3),
Tetsuro Onitsuka5), Fujimoto Yasushi3),
Matsuura Kazuto6), Kawabata Kazuyoshi7)
Object
This study was held to determine the proper area of dissection of the paratracheal lesion in patients with pyriform sinus
cancer of hypopharynx.
Methods
Clinical records, between 2006 and 2008, patients in multicenter undergoing total pharyngolaryngectomy were retrospectively evaluated. Among the total 281 cases of hypopharyngeal cancer, 118 cases underwent initial surgical treatment
due to pyriform sinus cancer. The management of the paratracheal dissection, thyroid resection, pathological findings,
and clinical course was studied.
Result
A total of 110 men and 8 women enrolled, the mean age was
66.9 years old, and the mean follow-up periods was 34.2
months. In the series, 15 patients were cT2, 53 were cT3, and
50 were cT4. Clinical node assessment revealed cN0 in 26 patients, cN1 in 15, cN2 in 72, and cN3 in 5. The occurrence of
local metastasis to the paratracheal lymph node was bilateral
in 3 patients, ipsilateral in 13, and contralateral in 6. The rate
of local invasion to the thyroid was 8.5% (10!
118). The rate of
local recurrence in the paratracheal lesion was 3.4% (4!
118).
Conclusion
Ipsilateral neck dissection and thyroid lobectomy is necessary in patients with pyriform sinus cancer. In patients with
N2c or cervical esophageal invasion, additional bilateral paratracheal dissection is preferred.
Department of Otolaryngology, Head and Neck Surgery,
Kagoshima University Graduate School of Medical and Dental
Sciences, Japan
Keiichi Miyashita, Yuichi Kurono
Background: Transcervical resection of hypopharyngeal carcinoma is rarely feasible because of potential swallowing
function damage after surgery. In April 2011, we began employing transoral video-laryngoscopic surgery (TOVS) with
Weerda type laryngoscopy and endoscopic submucosal dissection (ESD) using curved pharyngoscopy. Since that introduction, we have performed transoral removal of primary
and early hypopharyngeal carcinoma in cooperation with the
Departments of Digestive Medicine and Surgery of our institution. The aim of this study was to investigate the incidence
of regional recurrence after surgery and additional treatments utilized.
Methods: We retrospectively examined the records of patients who underwent transoral resection of early hypopharyngeal carcinoma from April 2011 to November 2013 in the
Department of Otolaryngology, Head and Neck Surgery at
Kagoshima University Hospital, Japan. Tumor size and location, and surgical margins in recurrent cases were evaluated.
Results: Thirty patients underwent that surgery at our hospital during the study period. All were male, with ages ranging from 46 to 85 years (average 65.9 years). Early hypopharyngeal carcinoma was diagnosed based on findings of upper
digestive (21 cases, 70%) or laryngeal flexible (9 cases, 30%)
endoscopy with narrow band imaging. In nearly all cases, the
tumor was located in the piriform sinus or posterior wall,
thus a hypopharyngeal subsite. There were 15 cases (50%) of
early hypopharyngeal carcinoma, each with concurrent
esophageal or gastric cancer. Nine cases (30%) were diagnosed as local recurrence from findings of a periodic endoscopic examination. Those sites of recurrence were not only
primary but also other lesions. All patients were alive and
without swallowing impairment at the time of writing, except for 1.
Conclusion: Recurrence after transoral resection of hypopharyngeal carcinoma requires additional treatment, such as
secondary transoral resection, chemoradiotherapy, or both.
Early hypopharyngeal carcinoma occurring as multiple lesions or extensive in the larynx tended to show a high rate of
recurrence.
389
Poster Presentation
E-P3-3
E-P3-4
Investigation on the multiple primary cancer in patients with hypopharyngeal cancer
A novel laryngoscopic technique to expose the hypopharyngeal space
Departmento of Otolaryngology, Shimane University, Faculty
of Medicine, Japan
Department of Otolaryngology, Head and Neck Surgery, Kanazawa University, Japan
Noriaki Aoi, Ichiro Morikura, Yasuhiko Shimizu,
Takafumi Fuchiwaki, Yukie Hotta, Hideyuki Kawauchi
Shigeyuki Murono, Tomokazu Yoshizaki
Background; Early detection of hypopharyngeal cancer is
very difficult, and it is discovered as advanced cancer, so its
prognosis is very poor. Moreover, multiple primary cancer
(MPC) also poses a problem, and its frequency is considered
to be around 20-50% in patients with hypopharyngeal cancer.
On the other hand, there is the way of thinking that another
cancer can be discovered earlier, if first cancer could be followed up severely .
Purpose; It is investigated whether the existence of MPC affects the stage or survival rate of the patients with hypopharyngeal cancer.
Method; The stage or survival rate of 134 cases of hypopharyngeal cancer together with or without MPC were examined retrospectively.
Results; There were 60 MPC patients out of 134 cases including 20 synchronous cases, 32 metachronous cases, and 8 synchronous and metachronous cases. The most common site
for MPC development was the esophagus (20.9%), followed
by the stomach (12.7%). In the case with MPC, hypopharyngeal cancer was discovered in earlier stage, and 5 year survival rate was significantly better compared with non MPC
patients.
Discussion; There is a possibility that hypopharyngeal cancer was discovered at an earlier stage with gastrointestinal
endoscopy in the case with the past of an esophagus cancer
or stomach cancer, since of severe follow up and increase of
recognition of MPC in gastroenterologist. It is a future subject that till when gastrointestinal endoscopy should be conducted after fist cancer, because there was the case that hypopharyngeal cancer developed ten years after radical treatment of stomach cancer.
390
Background: The hypopharyngeal space is difficult to observe the whole circumstance even with a flexible laryngoscope because it is a closed space. Various maneuvers have
been described to improve the view during laryngoscopy.
Recently, a new technique, named the modified Killian s
method (Sakai et al. Auris Nasus Larynx, in press), was introduced to observe a wider range of the hypopharyngeal
spaces.
Purpose: In this study, we investigated how frequently this
procedure improved a view of pyriform sinus (PS), postcricoid (PC) and upper esophageal sphincter (UES).
Materials and methods: Forty-four outpatients, consisting of
27 after (chemo)radiotherapy ((C)RT) for laryngeal or hypopharyngeal cancer, 7 after transoral surgery for laryngeal or
hypopharyngeal cancer, and 10 with other laryngeal or hypopharyngeal diseases, underwent the modified Killian s
method. Range of hypopharyngeal view was divided into five
grades; Grade 1, visible within PS; Grade 2, visible range between groups 1 and 3; Grade 3, visible whole PC; Grade 4, visible range between groups 3 and 4; Grade 5, visible UES.
Mann-Whitney U-test was used for statistical analyses.
Results: Six (13.7%), 6 (13.7%), 23 (52.3%), 2 (4.5%) and 7 (15.9%)
patients belonged to Grade 1, 2, 3, 4 and 5, respectively. Mean
scores of grade were 2.78 in patients with RT (n=27) and 3.12
in patients without RT (n=17) (p=0.52), 2.74 in patients with
CRT (n=19) and 3.04 in patients without CRT (n=25) (p=0.55),
3.00 in patients with hypopharyngeal disease (n=16) and 2.86
in patients with other diseases (n=28) (p=0.87).
Conclusion: A newly proposed technique, the modified Killian s method enabled observation of the entire hypopharyngeal space in most cases even after (C)RT.
Poster Presentation
E-P4-1
E-P4-2
The role of photodynamic therapy (PDT) in palliative
endoscopic treatment of patients with malignant
esophageal stenosis
Photodynamic therapy (PDT) in patients with early
(STAGE I) oesophageal cancer
Hertzen Moscow Oncology Research Institute, Russia
Victor Sokolov, Pavel vladimirovich Pavlov,
Elena stanislavovna Karpova
Background: From 2000 to 2013 was performed stenting of
the esophagus, stomach, duodenum at 538 patients. We used
Choo and Hanaro stents (M.I. Tech) in 65%, Gianturco-Z
stents (Wilson-Cook) in 23%, Ultraflex stents (Boston Scientific) in 5%, Ella stents (Ella CS) in 4%, and Biotech stents in
3% of cases.
Methods: Indications for stenting were: dysphagia, caused by
tumor stenosis in 506, iatrogenic perforation of the esophagus in 4, esophago-mediastinal and esophago-respiratory fistula in 15, anastomotic failure after surgery in 13 cases. 478
patients had signs of disease prevalence: metastases or ingrowth into adjacent organs. 60 patients had no evidence of
metastases. These patients underwent multy-course PDT
with laser irradiation of tumor through translucent wall of
the stent.
Results: Thirty-day post-stenting mortality at 538 patients
occurred 14%. Median survival 5,3 months. The best results
(median survival 8,7 months) achieved in a group of 60 patients, who underwent multy-course PDT through the stent.
The first session runs in 0,5-1 month after stenting, the second and subsequent sessions of PDT in interval of 1-2
months. Number of PDT sessions for each patient ranged
from 3 to 12. Average number of sessions was 5. PDT was
performed by domestic lasers with a wavelength corresponding to each photosensitizer (radachlorin, photosens or
photogem). For the delivery of laser radiation, we used
quartz fiber with diameter of 400 microns with a diffuser at
the distal end (1-3cm length) giving matrix of a laser light at
360 degrees. Photosensitizer, dose of laser irradiation and the
interval between treatments were selected individually.
Conclusions: in cases of esophageal tumor stenosis without
metastasis, with contraindications to radiation therapy using
of self-expanding metal stents with multy-course PDT is the
best treatment option with good clinical outcome, improved
quality of life and small number of complications.
Department of PDT, Moscow City Oncological Hospital N 62,
Russia1), Endoscopy department P.A.Hertzen Research Oncological Institute Russian Federation2), Department of PDT,
Moscow City Oncological Hospital N 62, Russian Federation3)
Dmitry Sokolov1), Viktor Sokolov2), Makhson Anatoly3)
Objectives: About 8 000 patients with oesophageal cancer
have been revealed in Russia only. Unfortunately, in 70% of
patients, the initially identified disease is diagnosed as stage
III-IV, thus predetermining the failed treatment. Revealing
of early oesophageal cancers does not exceed 5%. Most of the
early cancer forms are diagnosed in individuals over 60
years old who have expressed accompanying pathology. For
this category of patients, new methods of treatment-one of
which is endoscopic PDT-have been approached in the recent decades.
Material and Methods: From 2005 to 2013 we treated 27
esophagus, stomach and colon cancer patients (31 tumors)
using PDT. Five patients (10 tumors) had early stage oesophageal cancer. Photogem and Radachlorin photosensitizers
were injected intravenously 3-48 hours prior to the PDT
treatment. For the PDT session we used a domestic diode lasers with wave-length of 630, 662nm (more than 100 J!
cm2).
Microlenses and 1-2 cm cylindrical tips were used for laser
radiation. PDT was prescibed for patients who were not appropriate for ESD.
Results: In group of patients with early oesophageal cancer
we achieved complete regression in all cases. Two out of 5
patients had recurrence of tumor in 1 to 4 years, and they
were successfully treated with repeated PDT.
Conclusions: We applied PDT to treat more difficult patients
with early (stage I) oesophageal cancer. The analysis of the
results showed high effectiveness of developed PDT methods in treating patients with early oesophageal cancer. In
one patient, there was a scarry stricture of esophagus, which
was finally removed by balloon dilatation. We have not revealed any toxic reactions to or decrease in tumor sensibility
during the repeated PDT courses.
391
Poster Presentation
E-P4-3
E-P5-1
Clinical outcomes and problems of definitive chemoradiotherapy for esophageal cancer
Esophagectomy in patients 70 years of age and older
with esophageal cancer
Department of Gastroenterological Surgery, National Kyushu
Cancer Center, Japan1), Gastroenterological Surgery, National
Kyushu Cancer Center, Japan2), Department of Radiology, National Kyushu Cancer Center, Japan3)
Akinori Egashira1), Yasushi Toh2), Manabu Yamamoto2),
Kippei Ohgaki2), Shohei Yamaguchi2), Kazuhito Minami2),
Naonobu Kunitake3), Kazuhiro Okushima3),
Takeshi Okamura2)
Objective
Multi-modality approach, including surgery, chemotherapy
and radiotherapy is essential for treating esophageal cancer.
However, surgical resection could not be applied for all patients with resectable tumors because of the co-morbidities
and patients refusal. The purpose of this study is to evaluate
the clinical outcomes and problems of definitive chemoradiotherapy (dCRT) for esophageal cancer, and to discuss the
prognostic factors for the patients with esophageal cancer
who underwent dCRT.
Materials and methods
Two hundred and forty-five patients (pts) with esophageal
cancer who underwent dCRT from 2003 to 2012 were analyzed for treatment outcomes and prognoses.
Results
The median age of the patients was 67.4 years. There were
215 male and 30 female pts. For clinical stage defined by
Japanese Classification, 19 pts, 57 pts, 29 pts, 43 pts and 97
pts were cStage 0, I, II, III and IVa, respectively. The rates of
complete response (CR) obtained by dCRT were 100%, 94.7%,
72.4%, 37.2%, 12.2% in cStage 0, I, II, III, IVa, respectively. 5year survival rates were 77.8%, 64.6%, 39.0%, 23.1%, 11.3% in
cStage 0, I, II, III, IVa, respectively. Recurrent diseases after
achievement of CR were recognized 10.5%, 33.3%, 28.6%,
43.7%, 69.2% in cStage 0, I, II, III, IVa, respectively. Adverse
effects (Grade 3 or more) were observed in 48.5% of patients,
and majority of them were bone marrow suppression, followed by nausea, appetite loss and mucositis. Although the
treatment outcomes were inferior to those by surgical resection, the prognosis for patients who achieved the CR by
dCRT was most promising, especially for cStageIVa disease.
On multivariable analysis, status of lymph node metastasis,
completion of dCRT and achievement of CR were significant
independent prognostic factors for esophageal cancer patients who underwent dCRT.
Conclusion
It is important to achieve CR by dCRT for improving the
therapeutic results and completion of dCRT may contribute
to improve prognosis.
392
Department of Surgery, National Fukuoka-Higashi Medical
Center, Japan
Takefumi Ohga, Rumi Matono, Yoshiyasu Nagao,
Hideki Ijichi, Tadahiro Nozoe, Takahiro Ezaki
Background: The patients with esophageal cancer tend to be
elder and men. The elderly patients have frequently dysfunction of critical organs. Surgical treatment for elderly
esophageal cancer patients has been considered to be the
most difficult and the indications for surgery remain controversial.
Aim: The puropose of this study was to clarify the indications for an esophagectomy in elderly patients (especially patients over 70 years of age) with esophageal cancer.
Materials and methods: A total of 25 patients with esophageal cancer who underwent an esophagectomy were divided
into two groups according to age, namely, groups I (<70
years, n=16) and II (>or=70 years, n=9). In group II, surgery
was only done in patients with PS0 or 1, as well as almost
normal cardiac and pulmonary functions.
Results: The morbidity rates of group I and II were 68% and
33%, respectively. Pulmonary complications in each groups
occurred in 13% and 0%, respectively. In group II, the mortality and 30-day mortality rates were 0.0% and 0.0%, respectively, and pulmonary complications did not occurred (0.0%).
The average hospital stay period after the operation in
group I and II were 56.0 days and 50.4days, respectively. The
hospital mortality retes in group I and II were 6.25% and
0.0%, respectively. Overall medium survival period in group I
and II were 447 days (143-1248) and 979 days (105-1680). The
number of 3 years above survival persons is two (12.5%) and
four (44%) in group I and II.
Conclusions: In the elderly, careful perioperative management is needed while paying special attention to pulmonary
complications. However, when the indications for surgery
can be strictly determined, an esophagectomy is considered
a viable treatment alternative with satisfactory prognosis
even in patients 70 years of age and older without any increased morbidity or mortality.
Poster Presentation
E-P5-2
E-P5-3
Clinical signifivance of FDG-PET in screening of synchronous cancer of other organs in patients with
esophageal cancer
TGFBI expression predicts the therapeutic effect of
chemoradiation therapy in esophageal carcinoma
Department of General Surgical Science (Surgery 1), Gunma
University Graduate School, Gunma, Japan1), First Department
of Surgery, Dokkyo Medical University, Tochigi, Japan2)
Tatsuya Miyazaki1), Makoto Sohda1), Tetsuya Higuchi1),
Naritaka Tanaka1), Makoto Sakai1), Takehiko Yokobori1),
Masanobu Nakajima2), Minoru Fukuchi1),
Yoshito Tsushima1), Hiroyuki Kato2), Hiroyuki Kuwano1)
Aim: We investigated the significance of pretreatment
screening for patients with esophageal cancer by 18Ffluorodeoxyglucose positron-emission tomography (FDGPET). Patients and Methods: We retrospectively evaluated
the clinical significance of screening in 200 patients with primary esophageal cancer using FDG-PET. Results: Of 200 patients, 34 (17%) had synchronous multiple primary tumors; 31
patients had two types of cancer (15.5%) and three patients
had three types (1.5%). The 37 second and third primary tumors were 13 of stomach cancer (35.1%), 13 of head and neck
cancer (35.1%), seven of the colon (18.9%) and two of lung
(5.4%). When PET was performed at initial treatment for
esophageal cancer, the diagnostic sensitivity of FDG-PET!
Computed tomography (CT) for the second and third synchronous primary cancer were for the stomach, 53.8% (7!
13);
head and neck, 61.5% (8!
13); colon, 42.9% (3!
7); and lung, 50%
(1!
2), for an overall sensitivity of 54.1% (20!
37 sites). Conclusion: FDG-PET!
CT for patients with esophageal cancer may
find both metastases from the primary esophageal cancer
and other types of synchronous primary cancer.
Department of General Surgical Science, Graduate School of
Medicine, Gunma University, Japan
Daigo Ozawa, Takehiko Yokobori, Tatsuya Miyazaki,
Hiroaki Honjo, Keigo Hara, Makoto Sakai, Makoto Soda,
Hiroyuki Kuwano
Background
Usefulness of neoadjuvant chemotherapy with 5-FU +CDDP
for esophageal squamous cell carcinoma (ESCC) has been
proven. Recently, for further improvement of the therapeutic effect, chemotherapy added docetaxel have been performed. However, outcome of ESCC is not still sufficient, and
new markers as tools for tailor-made therapy is required.
Transforming growth factor β induced (TGFBI), which induced by TGF-β in several types of cells, was first identified
in a human lung adenocarcinoma cell line. Mutations of the
TGFBI gene are involved in several corneal dystrophies. Recently, it was reported that TGFBI expression in ovarian
cancer stroma is associated with the sensitivity of chemotherapy.
In this study, we examined the relationship of TGFBI expression and sensitivity to chemotherapy of ESCC.
Materials & Methods
1) TGFBI expression was examined by immunohistochemistry (IHC) in biopsy samples which were taken before treatment from 15 ESCC patients who received neoadjuvant
chemoradiation therapy using docetaxel (docetaxel 8mg!
m2,
radiation 40Gy). After surgery, we investigated the relationship between TGFBI expression and pathological evaluation
of chemoradiation therapy.
2) ESCC cell line TE-8 was treated with recombinant TGFBI
protein, and chemosensitivity to docetaxel was investigated
in vitro by WST assay.
Results
1) The expression of TGFBI was shown mainly in cancer
stroma by IHC. Its expression were classified into four
stages (0∼3+) by IHC intensity and extent (0:1+:2+:3+=3:3:7:
2 cases). The higher TGFBI expression was, the better response chemoradiation therapy was in pathological evaluation (p=0.034).
2) WST assay indicated that the sensitivity of TE-8 to docetaxel was enhanced by recombinant TGFBI.
Conclusions
The expression levels of TGFBI may be a marker to predict
the therapeutic effect of chemoradiation therapy using docetaxel in ESCC patients. Furthermore, TGFBI might be a
therapeutic target.
393
Poster Presentation
E-P6-1
E-P6-2
Tissue blood flow change of the gastric tube after microvascular vein anastomosis for esophageal reconstruction
Prognoses of the hypopharyngeal or cervical esophageal squamous cell carcinoma after treatment by operation or CCRT
Surgery, NTT Medical Center Tokyo, Japan
Hitoshi Satodate, Satoshi Nara, Atsuki Nagao,
Noie Tamaki, Kei Ito, Kaoru Furushima,
Yasushi Harihara
BACKGROUND
Gastric tube formation with cervical esophagogastrostomy
via the antesternum is an effective method of reconstruction
after esophagectomy to treat esophageal cancer. But the incidence of anastomotic leak after esophageal reconstruction
for cancer is reported to be 0-30%, and cervical anastomoses
have higher leak rates (10-25%). Impaired blood flow of the
upper end of the gastric tube clearly poses a crucial risk for
anastomotic leak, and the improvement of local blood flow is
undoubtedly useful for decreasing the risk.
METHODS and RESULTS
We applied additional microvascular anastomosis procedurethe superdrainaging and the supercharging technique-using
the left gastroepiploic vessels as donor vessels, and the left
cervical transverse artery and the left external jugular vein
as recipient vessels. In our institution, this procedure is
mainly applied to the patient of cervical esophageal cancer
patient because the length of the gastric tube has to be long.
Microvascular anastomosis procedure was performed as follows: 1) The gastric tube and cervical esophagus were anastomosed, 2) vein-left gastroepiploic vein and left external
jugular vein-were anastomosed with a 9-0 nylon under the
microscope, 3) stump of the donor artery-left gastroepiploic
artery-was opened (de-clamped), and evaluate the blood outflow from the donor artery stump, 4) the amount of the outflow was enough, arterial anastomosis was not performed,
regarding as tissue blood flow was sufficient, 5) in case of the
amount of the outflow was diminished, regarding as tissue
blood flow was not sufficient, then artery-left gastroepiploic
artery and left cervical transverse artery were anastomosed
(supercharging) under the microscope. We named this procedure as de-clamped test, and have been performed for over
sixty consecutive patients. Only one leak has been experienced in this series of patients.
CONCLUSION
This procedure can be relatively easily applied to the
esophageal cancer patients and potentially contribute to reduce the risk of anastomotic leak. We will show our clinical
practice, including one case of leak patient experience.
394
Department of otorhinolaryngology-Head and Neck Surgery,
Ryukyu University School of Medicine, Japan
Hiroyuki Maeda, Shinya Agena, Asanori Kiyuna,
Mikio Suzuki
Prognoses of the hypopharyngeal or cervical esophageal carcinoma are poor in comparison with others in the head and
neck region in generally. However, in proportion as an innovation of the technical skill in surgical operation progress,
prognoses of these were improved gradually. Particularly,
reconstruction of hypopharynx or esophagus using free jejunal transfer brought better results in five years survival rate
in the present. Outcome in our establishment is achieved
about 60% over. However, curative operation require victim
as loss of vocal function and communication. Recently, instead of these operative methods, concurrent chemoradiotherapy (CCRT) is spread all over the world. We can also acquire these new methods. By using these two main trunks of
treatment, we succeeded in improving at the ratio of local
control remarkably. Otherwise, difficult problems as control
of distant metastasis were left for us.
We investigated prognosis of hypopharyngeal or cervical
esophageal squamous cell carcinoma after treatment by the
operation or CCRT in term from 2006 to 2013. We will be to
report these outcomes in detail and to consider to some problem that we must improve in future.
Poster Presentation
E-P6-3
E-P7-1
Transnasal esophagogastroduodenoscopy (EGD) in
diagnosis of hypopharyngeal cancer
Effects of thyroidectomy to hypo-pharyngeal esophageal acid reflux
Department of Otolaryngology, National Taiwan University
Hospital, Taiwan1), Department of Internal Medicine, National
Taiwan University Hospital, Taiwan2)
Cheng-Ping Wang1), Tseng-Cheng Chen1), Jenq-Yuh Ko1),
Pei-Jen Lou1), Tzu-Yu Hsiao1), Ping-Huei Tseng2),
Yi-Chia Lee2)
Background:
Primary hypopharyngeal cancer has a higher risk for primary esophageal cancer. In the past 6 years, we have demonstrated the feasibility of transnasal esophagogastroduodenoscopy (EGD) without conscious sedation to evaluate hypopharyngeal cancer with tissue diagnosis and regularly
screen the entire esophagus at one time.
Methods: Since 2007, more than 200 patients with newly diagnosed hypopharyngeal cancer were evaluated by transnasal EGD without conscious sedation. The detection of esophageal lesions involved a sequential approach with conventional white light, narrow-banding imaging (NBI), and Lugol
chromoendoscopy.
Results:
Around 45% of the patients are found to have simultaneous
esophageal lesions, including second primary esophageal invasive cancer in around 20%, esophageal dysplasia of various
degrees in 10% and lugol voided lesion in the other 15%.
Compared with esophageal cancer diagnosed in general
population, the stage of esophageal cancers in this cohort is
significantly lower, which may indicate better survival. Compared with historic control and the cohort without esophageal screening, the cohort receiving regular screening of the
esophagus by use of transnasal EGD has a statistically significantly better survival. By the way, more than 50% of the
patients with newly diagnosed hypopharyngeal cancer were
diagnosed by transnasal EGD to have upper gastrointestinal
(GI) functional disorders, including peptic ulcers and reflux
esophagitis. It may be beneficial to improve the patients quality of life if taking care of these functional disorders when treating cancer.
Conclusion:
Unsedated transnasal EGD is a safe, tolerable and accurate
endoscopic technique for pathological diagnosis of hypopharyngeal cancer and screening of simultaneous esophageal
cancer during a single session. Hypopharyngeal cancer in
Taiwan has a high prevalence of simultaneous esophageal
cancers and upper GI functional disorder.
Department of Otolaryngology, Nagoya City University, Japan
Yuki Hamajima, Motohiko Suzuki
Overview
Thyroidectomy is surgical procedures often done in general
practice. Cervical surgical procedure sometimes causes damages to pharynx and cricopharyngeus muscles. This is considered because surgeon needs to peel off near the cricopharyngeus muscle and anterior cervical muscles to preserve
recurrent nerve. After surgery, complains of pharyngeal discomfort sometimes occur, and these complains usually
treated because of the damages to these muscles. However
the thyroidectomy sometimes cause cricopharyngeal muscle
dysfunction and acid reflux at the upper esophageal would
be worse, because acid reflux directly provoked pharyngeal
discomfort. So we underwent a pH monitoring to the patients of thyroidectomy before and after the surgery, and
compared the degree of acid reflux in the hypo-pharynx and
lower esophagus.
Subjects and methods
In Nagoya City University Hospital, the patients of scheduled thyroid tumor surgery with throat discomfort, male 1
female 8 patients were recruited. We underwent 24 h pH
monitor on 2 days before and 1 week after surgery. We use
the Digitrapper 24 h pH monitor (Medtronic), using the dualprobe15 cm intervals. Probe inserted in the nose while
checking in the larynx fiber scope, upper probe is detained in
a hypo-pharynx and the bottom probe can be detention near
the 5 cm above the lower esophageal sphincter. Acid reflux
ratio (%), the number of acid reflux (times), and the duration
of acid reflux (seconds) were compared before and after surgery. Also we use the FSSG questionnaire to detect gustroesophageal-reflux (GER) at the same time.
Results
The acid reflux got worse in the five patients after operation.
In the worse cases, some patients were over 70 years old,
some were added lymphadenectomy surrounding trachea,
because suspected malignant. Some took more than 3 hours
operating time. Our results showed that the acid reflux
would be worse not only at the hypo-pharynx but also at the
lower esophagus. This results showed residual influence of
general anesthesia may remain on the digestive 1 week after
the operation. At the lower esophagus, the number and duration of acid reflux were increased, however, at the hypopharynx, the number of acid reflux was decreased, and the
duration of acid reflux was increased. This means upper
esophagus sphincter was relaxed after operation. Every case
improved throat discomfort within 3 months, and no cases
prolonged healing.
395
Poster Presentation
E-P7-2
E-P7-3
Long-term prognosis of differentiated thyroid carcinoma
Molecular analysis and clinical features of the parathyroid cancer; A case study
Department of Otorhinolaryngology, Head and Neck Surgery,
Osaka Red-Cross Hospital, Japan
Koichiro Yamada, Shinzo Tanaka
Objective: Differentiated thyroid carcinoma (DTC) generally
has a good prognosis. However, there are high-risk cases in
which the tumor becomes life-threatening for the patient.
The aim of this study was to detect high-risk factors in DTC
patients.
Patients and Methods: The study included 166 patients
(mean age 56.4 14.1 years, 35 men and 131 women, 144 patients with papillary carcinoma and 22 with follicular carcinoma, mean follow-up 13.1 4.8 years) who underwent surgical treatment at Osaka Red Cross Hospital between 1991 and
2000. TNM classification and staging were based on UICC 7
th classification. Sixty patients were classified as T1-2, 84 as
T3, and 22 as T4. Eighty-one patients were classified as N0,
40 as N1a, and 45 as N1b. A total of 164 patients were classified as M0 and 2 patients as M1. Sixty patients were classified as stage I-II, 54 as stage III, and 52 as stage IV. Causespecific survival rates were calculated by the Kaplan-Meier
method and were compared using the log-rank test.
Results: Fourteen patients died from DTC. The causespecific 10-year survival rate was 96.6%, and the 15-year survival rate was 92.0%. Cause-specific survival was significantly influenced by T, N, M and staging (T4 vs T1-2, T4 vs
T3, N1b vs N0, M1 vs M0, stage IV vs stage I-II, stage IV vs
stage III: p<0.05). Among T4, N1b and M1, T4 and M1 were
significant risk factors, based on multivariate analysis (Cox
proportional hazards analysis).
Conclusion: Extensive local invasion (T4), lateral lymph node
metastases (N1b), and!
or distant metastases (M1) at diagnosis showed a clearly lower cause-specific survival.
396
Otolaryngology, Osaka General Medical Center, Japan1), Surgery, Noguchi Thyroid Clinic and Hospital Foundation, Japan2),
Urology, Osaka General Medical Center, Japan3), Pathology,
Osaka General Medical Center, Japan4)
Keisuke Enomoto1), Shinya Uchino2), Miki Nagai1),
Kazuya Takeda1), Shotaro Harada1), Ryoichi Imamura3),
Kohki Shimazu4), Hiroaki Fushimi4), Yoshiharu Sakata1)
Parathyroid cancer is a very rare endocrine carcinoma. Only
a few studies have provided their clinical course and molecular analysis such as HRPT2, EGFR and RAS mutations. This
report demonstrates the clinical course and the molecular
analysis of a case with parathyroid carcinoma. A 62-year-old
female was admitted to our hospital with hoarseness. In his
past history, he had suffered from parathyroid surgery 6
years ago. His blood biochemistry findings were notable for
the high level of calcium (Ca) and intact parathyroid hormone (iPTH) (13.4 mg!
dl and 192.9 pg!
ml, respectively). Computed tomography showed a left parathyroid tumor (27 mm
in diameter), which invaded to esophagus. She was diagnosed with parathyroid cancer, and underwent curative surgical resection. Pathological diagnosis was confirmed as a
parathyroid cancer. EGFR immunostaining was performed,
but not show over expression of EGFR. Additionally, molecular analysis was performed. HRPT2 gene and Ras gene mutation was not found in pathological specimen. The Ca and
iPTH level were raised one month after surgery, again.
Cetuximab and docetaxel were administrated, however a patient was died of the disease 8 months after surgery. We report here the clinical features and the molecular analysis of
the parathyroid cancer from our experience.
Poster Presentation
E-P7-4
E-P8-1
Acute spontaneous intrathyroid hemorrhage with thyroid pain and laboratory findings
Solitory laryngeal neurofibroma: Case report and a review of literature
Department of otolaryngology, Takeda General Hospital, Japan1), Department of otolaryngology, head and neck surgery,
Kansai medical universtiy, Japan2)
Department of Respirology & Critical care medicine, Xiangya
Hospital of Central South University, China
Yasutaka Yun1), Masao Yagi2), Yasunori Osumi1),
Masahiko Izumikawa1), Tomoda Koichi2)
Objectives:
We evaluated the clinical features of 8 patients with an acute
spontaneous intrathyroid hemorrhage (ITH) with an episode
of an abrupt painful swelling of the thyroid.
Study design and patients:
Our study was a retrospective study involving 8 ITH patients (7 females and 1 males) with the mean age of 48.25
(range17-79 years). They were diagnosed with ITH at our
hospital during the period from August 2008 to October
2013. Diagnosis of ITH was defined as a cystic lesion of the
thyroid which was confirmed by ultrasonography and!
or
computed tomography, fine-needle aspiration, clinical course,
and laboratory findings.
We all evaluated serum free T3 (FT3), free T4 (FT4), TSH,
thyroglobulin (Tg), C-reactive protein (CRP) levels, antithyroglobulin antibody (TgAb), TSH-binding inhibitor immunoglobulin and white blood cell in acute phase. We conducted
ultrasonography of the thyroid to assess hypoechoic areas
that accompanied tenderness.
Results:
TSH, FT3 and FT4 were normal in all patients. CRP levels
were slightly elevated in 5 patients ranged from 0.03 to 1.63
mg!
dl. Tg were elevated in all patients ranged from 185.4 to
131000. All patients were negative for TgAb. One case presented with sudden massive swelling of the neck, and required tracheostomy. One case presented with hoarseness
because of the recurrent nerve palsy. Two cases underwent
thyroidectomy. Microscopic examination of the resected
gland revealed Adenomatous goiter.
Conclusion:
The patients with ITH demonstrated some of the symptoms
and laboratory findings that are characteristic of subacute
thyroiditis. Acute intrathyroid hemorrhage causing upper
airway obstruction can develop after not only trauma and
fine needle aspiration but also spontaneous bleeding.
Yuanyuan Li, Lili Zhang, Chengping Hu, Pengbo Deng
Objective: Disscuss and improve the understanding of the
clinical characters, diagnostic methods and treatments of
solitary laryngeal neurofibroma.
Background: A 26-year-old female who had presented with
dyspnea for half a year and underwent an endoscopic resection was finally diagnosed as supraglottic solitary neurofibroma. And we reviewed the literature on the clinical manifestations, diagnosis and managements of solitary laryngeal
neurofibroma.
Methods: We conducted a search of the published literature
before September 2013 in PubMed and MEDLINE using the
search criteria ( neurofiberoma and AND larynx ). After
elaborate screen, 10 solitary laryngeal neurofiberoma cases
were included in this review. Recent advances in treatment
had also been searched.
Results and Conclusions: Laryngeal neurofibroma rarely occurs and easy to be misdiagnosed, particularly for these patients only manifest as solitary lesion in larynx area. Final diagnosis relies on histopathology and immunohistochemistry.
Surgery is the best choice for the treatment of laryngeal
neurofibroma and microsurgeries using transoral endoscopy
followed by CO2 laser management of the surgical border
may be an effective and workable way to prevent recurrence. Long term follow-up is recommended due to the possibility of recurrence years later.
397
Poster Presentation
E-P8-2
E-P8-3
A case of actinomycosis of the larynx
Investigation of intubation-induced bilateral vocal fold
dyscinesia
Department of Otolaryngology, Nihon University School of
Medicine, Japan1), Department of Respiratory Surgery, Nihon
University School of Medicine, Japan2)
Yasuyuki Nomura1), Masatoshi Miura1), Teruo Toi1),
Takeshi Masuda1), Hiroki Sekine1), Takeshi Asakawa1),
Mitsue Shimamura2), Toru Furusaka1)
Background
Actinomycosis is a systemic bacterial infection and cervicofacial disease is the most common. However, the laryngeal involvement of actinomycosis is rare and there are only a few
cases of primary laryngeal actinomycosis in the literature.
We present a case of the bilateral vocal cords disease.
Case report
A 64 y.o. male complained hoarseness and visited a neighbor
ENT clinic. The bilateral vocal cords and anterior commissure of larynx were covered with a irregular white lesion
and he was introduced to our hospital with a suspected laryngeal tumor. The serum SCC was 1.8ng!
ml and whole
body scrutiny didn t show any malignant lesion. He had a history of diabetes mellitus, hypertension and hepatitis B. He
smoked 50 tobaccos per day and was diagnosed with COPD
at the respiratory division of our hospital. We took a biopsy
on his first visit to our outpatient clinic. Its pathological diagnosis was actinomycosis. Oral amoxicillin medication had
started and his hoarseness was cured in one month. However, the white lesion didn t disappear after four months of
medication. Therefore, we performed a direct laryngoscopy
under general anesthesia to confirm the lesion and re-biopsy.
The pathological findings revealed that there was no actinomycosis lesion in the specimen anymore and that amoxicillin
seemed to have been effective. We continued the medication
of amoxicillin and the vocal cords white lesion almost disappeared after one year. We then stopped the medication.
However, lung cancer was found ten months after his first
visit. He underwent a lobectomy of the upper left lung. His
post operative condition is favorable.
Conclusion
Actinomycosis of the larynx is very rare and supposed to
need long term treatment with by penicillin. It was important to follow to mention the additional disease especially
cancer as like the former literature reports.
398
Department of Otolaryngology, Toho University School of
Medicine, Japan
Koji Matsushima, Akira Hukuo, Kentaro Matsuura,
Takashi Ishigaki, Yutaro Ida, Hiroshi Osahune,
Mamiko Yasuda, Kota Wada, Hideo Edamatsu
<Background>
The cause of bilateral vocal fold dyscinesia is cicatricial contracture of posterior glottis or bilateral vocal fold paralysis.
To bilateral vocal fold dyscinesia patient with dyspnea, we
carry out tracheotomy first. After that, we examine various
tests and specify cause.
<Method>
Our investigation includes electromyography, period of Intubation, arytenoid cartilage mobility test under general anesthesia, and observation of subglottic via tracheostomy aperture in bilateral vocal fold dyscinesia patients tracheostomized in 2013.
<Results>
Ten bilateral vocal fold dyscinesia patients treated in 2013,
and tracheotomy was carried to six patients of them. In electromyography, one patient was accepted bilateral neurogenic change and two patients were unilateral neurogenic
change. Normal EMG waves was accepted in three remaining patients. Five patients had received long intubation manage in six patients. Intubation period was 14 to 35 days. In
observation of subglottic, cicatricial change of mucosa was
observed in all five patients. Mobility of arytenoid cartilage
was poor in all five patients, therefore the cause of bilateral
vocal fold dyscinesia was cicatricial contracture of posterior
glottis.
<Conclusion>
Longterm tracheal intubation is one of the main causes of
cicatricial contracture of posterior glottis. Usually, the intubation period was said to be two weeks at the longest, but in
this investigation, cicatricial contracture was observed at
two week intubation. From this investigation, reexamination
about intubation manage should be required.
Poster Presentation
E-P9-1
E-P9-2
15 times of sclerotherapy for a large hemangioma extending from the pharynx to the cervical esophagus; A
case report
Nodular hidradenoma of the left neck: A case report
Department of Otorhinolaryngology, Head and Neck Surgery,
Ehime University School of Medicine, Japan1), Kawakita Clinic,
Japan2), Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Kochi University, Japan3), Department of Otolaryngology-Head & Neck Surgery, Graduate
School of Medicine, Kumamoto University, Japan4)
Aki Taguchi1), Naoya Nishida1), Seiji Kawakita2),
Masamitsu Hyodo3), Eiji Yumoto4)
Adult pharyngeal hemangiomas are uncommon neoplasms
and relatively easily diagnosed in flexible laryngoscopy, computed tomography (CT), and magnetic resonance imaging
(MRI). The treatment course for pharyngeal hemangioma is
decided with consideration of tumor size, region, and extension range. In principle, surgical resection is the best course
for complete cure. But if it is an unresectable case, we choose
a laser resection or sclerotherapy.
We report a 16-year-old male with hemangioma from oropharynx to the cervical esophagus with its continuous sclerotherapy. He had complained of pharyngeal swallowing
pain for 2 months, and subsequently presented with oral
bleeding at our clinic. Endoscopy and MRI revealed a large
hemangioma extending from the pharynx to the cervical
esophagus. Due to its location and extension, sclerotherapy
with polidocanol1% was carried out. Total dosage was given
from 4ml to 25ml. After the sclerotherapy, the hemangioma
was significantly reduced and the bleeding was also stopped,
but the re-enlargement was found after a while; therefore, a
sclerotherapy with the same medical agent has been conducted for total 15 times from 1997 until February 2012. Severe complications were not observed. One year and 10
months have been passed since the last sclerotherapy, but
any enlargement tendency is not found so far. Presently, we
do not close the tracheostomy.
Sclerotherapy is a relatively simple and effective method,
that is a valuable and promising treatment for hemangioma
in selected cases.
Otolaryngology, Nishi-Yokohama International Hospital, Japan1), Department of otolaryngology, Yokohama City University Medical Center, Japan2), Department of otolaryngology,
Minami-Kyosai Hospital, Japan3), Department of otolaryngology, Yokohama Graduate Medical School, Japan4)
Toshiro Kawano1), Masaki Matsuura1), Junichi Ishitoya2),
Ryo Ikoma3), Yasunori Sakuma2), Masahiro Takahashi4),
Nobuhiko Oridate4)
Nodular hidradenoma is a rare skin adnexal tumor most
likely arising from the epithelial cells of sweat glands. It is a
benign neoplasm commonly seen on the head, face, and extremities. Here we report a case of 57-year-old man with
nodular hidradenoma of the left neck. He had pain and swelling in his left neck at presentation. Enhanced computed tomography revealed cystic masses with partitions in left
neck. These cystic regions did not seem to adhere to the
neighboring tissues. The tumor in the left neck was removed
under general anesthesia. Histopathological examination revealed a cystic lesion containing mucinous fluid. The fibrous
capsule of the cyst had solid component and included
poroma cells that show tubular differentiation. The tumor
was diagnosed as a nodular hidradenoma of the left neck cervical cleft. No recurrence was observed for about 1 year after the surgery. A complete local excision after detailed radiological evaluation is recommended to prevent recurrence.
399
Poster Presentation
E-P9-3
E-P10-1
Descending necrotizing mediastinitis: Clinical analyses in 9 cases
Transoral videolaryngoscopic surgery (TOVS) for pharyngeal cancer with deflectable-tip EndoEYE
Department of otolaryngology and head & neck surgery, Kansai Medical University, Japan1), Department of otolaryngology,
Takeda general hospital2)
Tomofumi Sakagami1), Masao Yagi1), Fujisawa Takuo1),
Miyamoto Makoto1), Suzuki Kensuke1),
Utsunomiya Toshiki1), Yasutaka Yun2), Tomoda Koichi1)
Objective: Descending necrotizing mediastinitis (DNM) is a
severe infection caused by downward spread of deep neck
infection. DNM arises as a complication of odontogenic, pharyngeal, and other cervicofacial foci. Although most studies
are based on small patient populations with variety of data
on risk factors, etiology, and outcome, early diagnosis and
surgical intervention are crucial. The purpose of this study
was to analyze clinical data from 9 patients with descending
necrotizing mediastinitis originating from deep neck infection.
Method: We retrospectively reviewed clinical data from 9
cases with descending necrotizing mediastinitis originating
from deep neck infection between 2006 April and 2013 April
seen at the Hirakata hospital of Kansai medical university
and Takeda general hospital.
Results: The age of the patients ranged from to years old a
mean age of 64.1 years old. Of the 9 cases, 6 cases were male
and 2 cases were female. 5 cases had diabetes mellitus as an
underlying disease. The period between the onset and treatment ranged from 3 to 11 days (mean: 5.38). Five cases of
DNM arose from the inferior pole of peritonsillar abscess, 2
cases of DNM arose from the superior pole of peritonsillar
abscess, and one case of DNM arose from the retropharyngeal abscess. One patient died of sepsis and the other 7 patients are surviving without complication.
Conclusions: Usually peritonsillar abscess occurs in the superior pole of the tonsil. However, in our series of DNM patients, in particular the inferior pole type of peritonsillar abscess is the most underling cause. This may be explained
considering that the diagnosis can be relatively delayed and
a lower abscess of the tonsil can easily reach the mediastinum by gravity. As highly clinical suspicion and prompt diagnosis are critical to diagnosis DNM, computed tomography
(CT) including neck and chest may be useful because of its
ability to assess the presence and extent of infection and to
determine the appropriate surgical approach.
400
Otolaryngology, Tokai University, Japan
Kenji Okami, Akihiro Sakai, Ebisumoto Kouji,
Sugimoto Ryousuke
Objectives: Several types of minimally invasive transoral
surgery has been reported for the resection of the pharyngeal cancers. We previously reported en bloc resection under surgical microscope (Okami, et al. Head Neck 2013). In
this study we evaluate the usefulness of TOVS (Shiotani, et
al. Ann. Otol Rhinol Laryngol 2010) with deflectable-tip EndoEYE.
Patients and Methods: Patients were 18 cancer cases of 10
hypopharynx, 6 oropharynx, and 2 larynx which were resected by TOVS. The laryngo-pharynx was exposed with
Weerda distending laryngosocope or Davis mouth gag. The
tumor was resected en bloc under the clear view provided
with Deflectable-Tip EndoEYE (Olympus, Tokyo). The surgical view, accessibility of the instruments were compared
with the previous method.
Results and Discussion: Although the operative field was exposed with the same devices, the surgical view was much
improved with TOVS. The base of tongue could be also well
exposed. En bloc resection was carried out in all cases and
the post-operative function was satisfactory. The indication
will be expanded for more advanced cases.
Poster Presentation
E-P10-2
E-P10-3
Development and assessment of mouthpiece using
polyethylene terephthalate glycol in transoral robotic
surgery
Prognostic value of 18F-fluorodeoxyglucose uptake
before treatment for pharyngeal cancer
Department of Otolaryngology, Head and Neck Surgery Faculty of Medicine, Tottori University, Japan
Kazunori Fujiwara, Takahiro Fukuhara, Hiroya Kitano
Introduction: Transoral robotic surgery (TORS), performed
with da Vinci surgical system (da Vinci), has been defined as
a surgical approach for benign and malignant lesions of the
oral cavity and laryngopharynx. It provides several unique
advantages, which include a 3-dimensional magnified view,
ability to see and work around curves or angles, and the
availability of 2 or 3 robotic arms. However, at present, da
Vinci surgical system does not provide haptic feedback. The
potential risks specific to the transoral use of the da Vinci include tooth injury, mucosal laceration, ocular injury, and
mandubular fracture. To prevent the intra-operative tooth
injury, we made the mouthpiece using polyethylene terephthalate glycol (PETG), designed for the tooth shape of each patient. It is of strength suitable to prevent the tooth injury,
and 0.4mm in thickness.
Method: To assess the safety and the effect of the mouthpiece, we measured the dynamic load and the strain from the
endoscope to the tooth with the PETG-based and siliconbased mouthpiece. We press the endoscope against the tooth
model with 2-type mouthpiece and measured the dynamic
load using the Chikara sensor and the strain using strain
gage.
Result: The maximum dynamic load was 1.29 0.03 in the
PETG-based mouthpiece and 2.24 0.05 in the silicon-based
mouthpiece. The PETG-based mouthpiece decreased the
load against the tooth compared with the silicon-based
mouthpiece. The strain was -166.84 3.94 and 48.24 7.77 in
the silicon-based mouthpiece. The load direction was in parallel with tooth axis in the PETG-based mouthpiece and in
vertical with tooth axis in the silicon-based mouthpiece.
Conclusion: The PETG-based mouthpiece reduced the tooth
load compared with silicon-based mouthpiece and parallelized the load direction with tooth axis. The PETG-based
mouthpiece increases tooth safety in TORS.
Head and Neck Surgery, Aichi Cancer Center Hospital, Japan1), Radiological and Medical Laboratory Sciences, Nagoya
University School of Medicine, Nagoya, Japan2), Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan3), Radiology, Nagoya University Graduate School
of Medicine, Nagoya, Japan4)
Hidenori Suzuki1), Katsuhiko Kato2), Yasushi Fujimoto3),
Yoshiyuki Itoh4), Mariko Hiramatsu3), Shinji Naganawa4),
Yasuhisa Hasegawa1), Tsutomu Nakashima3)
Objectives: The purpose of this study was to evaluate an association found between overall survival of patients with
pharyngeal squamous cell carcinoma (SCC) and pretreatment 18F-2-fluorodeoxyglucose (18F- FDG) uptake, which
are assessed by positron emission tomography combined
with computed tomography (PET!
CT). Next, we asked
whether 18F- FDG uptake is correlated with overall survival,
independent of primary tumor sites in patients with pharyngeal SCC who underwent radical treatments such as surgery
and radiotherapy.
Methods: Forty-nine patients who were newly diagnosed as
resectable pharyngeal SCC underwent pretreatment 18FFDG-PET!
CT. We used the maximum standardized uptake
value (SUVmax) as 18F-FDG uptake. Overall survival rate
was calculated by the Kaplan-Meier method.
Results: Patients with SUVmax of the primary site ≧8 significantly exhibited shorter overall survival in univariate
analysis (p<0.04). Moreover, by Cox proportional hazards
model of multivariate analysis, SUVmax of the primary site
≧8 was a significant prognostic factor independent of clinical stage, primary tumor site and treatment group (p<0.03).
Conclusions: These results suggested that SUVmax of the
primary site obtained by pretreatment 18F-FDG- PET!
CT
assessment is an important prognostic factor in patients with
pharyngeal SCC.
401
Poster Presentation
E-P10-4
E-P10-5
Simple diagnostic methods of primary site of laryngeal
and hypopharyngeal cancer using ultrasonography
Digital image enhancement in the endoscope: Advancement and further progress
Department of Head and Neck Cancer, Kanagawa Cancer
Center, Japan1), Department of Medical Informatics Yokohama
City University Medical Center Japan2)
Madoka Kaneko Furukawa1), Masaki Furukawa2),
Akira Kubota1), Yousuke Kitani1), Kaname Satou1)
(Purpose)Accurate diagnosis of tumor extension to surrounding tissues or area such as paraglottic space, thyroid cartilage, cricoid cartilage and so on is necessary for determining cancer stage. CT scan
is the most popular diagnostic tool to evaluate tumor expansion or
invasion, but it is not always available to perform CT scan immediately at the first examination. Ultrasonography known as a simple
and harmless diagnostic device is able to make practical imaging
not only in still image but also movement. Further, ultrasonography
has advantage that it can be operated at outpatient clinic or examination room by clinicians ourselves. We evaluated the practical utility of ultrasonography to detect tumor expansion or invasion of primary site of laryngeal and hypopharyngeal cancer.
(Patients and methods) One hundred twenty-two patients with laryngeal and hypopharyngeal cancer diagnosed and determined
clinical stage in Kanagawa Cancer Center were analyzed. Laryngeal cancer patients were 60 cases (glottis 49, supraglottis 10, subglottis 1), and hypopharyngeal cancer patients were 62 cases (pyriformis sinus 52, posterior pharyngeal wall 8, pharyngo-esophageal
junction 2).
First, these patients were diagnosed by ultrasonography focusing
on tumor extension to surrounding tissues or area such as paraglottic space, thyroid cartilage, cricoid cartilage, and then ultrasonography findings were compared to the CT findings performed after ultrasonography.
(Results) Final T-classification of these patients using CT image
were as follows: laryngeal cancer: T1:19cases, T2:19cases, T3:15
cases, T4:7cases, hypopharyngeal cancer: T1:9cases, T2:22cases, T3:
18cases, T4:13cases. The numbers and percentage of patients those
primary tumor could be detected and evaluated by ultrasonography were as follows: laryngeal cancer: T1:1case(5%), T2:6cases(32%),
T3:15cases(73%), T4:7cases(100%), hypopharyngeal cancer:T1:3
cases(33%), T2:10cases(45%), T3:17cases(94%), T4:13cases(100%). It
was revealed that hypopharyngeal cancer was more easily detected than laryngeal cancer on early T stage. These ultrasonography findings of primary tumor localization were almost coincident
to the CT findings.
In all patients with tumor extension to surrounding tissues or area
(such as paraglottic space, thyroid cartilage, cricoid cartilage) diagnosed by ultrasonography, same findings were certificated by CT.
(Conclusion) Ultrasonography was thought to be simple and useful
diagnostic device for examination of primary site tumor extension,
in T2 or more T stage laryngeal cancer and T1 or more T stage hypopharyngeal cancer patients.
402
Department of Otolaryngoogy, Tokyo Medical and Dental
University, Japan1), Department of Head and Neck Surgery,
Tokyo Medical and Dental University, Japan2), Department of
Artificial Organs and Medical Device Creation, Tokyo Medical
Center3)
Atsunobu Tsunoda1), Takuro Sumi2), Kishimoto Seiji2),
Tsunoda Koichi3)
Image modification had used in laryngeal and pharyngeal observation for precise observation. One of image modification
technique, i-scan (Hoya-Pentax) had used in ENT clinic for 6
years. The basic technology of this method is image modification by computer. This image modification start with two
image modification surface enhancement (SE) and contrast
enhancement (CE). These function enabled enhancement of
subtle changes in surface structure (SE) and vascular or undermined structure (CE). Subsequently, tone enhancement
(TE) had developed which enhances changes of tissue especially in vascular structure. These image modification generated only by digital image processing.
Currently, new concept of image enhancement has developed. Using an optical filter passing around 400nm light
which equals to absorption frequency of hemoglobin. Coupled with digital this filtered light, observation of blood vessels become much easier. This new technique is named Optical enhancement (OE) and is currently equipped endoscopic device. In this report, we introduce this new image enhancement in the diagnosis of laryngeal and pharyngeal lesions.
OE mode 1 image strongly enhances vascular structure. The
image itself resembles that of narrow band imaging (NBI)
and which is no way inferior to NBI in detection of vascular
abnormality. OE mode 2 image has natural color texture and
this offers normal color image with enhancement of vascular
structure. This new technique provide superior and splendid
image in detection of slight laryngeal and pharyngeal lesions
and useful in early detection of lesions. This new modality requieres time of changes of optical filter, however, it does not
interfere observation in actual practice.
Poster Presentation
E-P11-1
E-P11-2
The effect of laryngotracheal separation in 40 children
with severe motor and intellectual disabilities
Efficacy of adenotonsillectomy on REM!
NREM sleep
lateral positions in pediatric sleep apand on supine!
nea syndrome
Department of Nutrition, Faculty of Health Care Science,
Chiba Prefectural University of Health Sciences, Japan1), Division of otorhinolaryngology, Chiba CHildren s Hospital2)
Fumiyo Kudou1), Yukiko Arimoto2), Atsuko Nakano2)
Intractable aspiration can be a life-threatening medical problem in children with severe motor and intellectual disabilities, and gastroesophageal reflux (GERD) likewise, because it
is closely related to aspiration. Children with disabilities like
those mostly have to stay at the hospital for their respiratory
infection, even though, they are under medical management.
Some reports say that laryngotracheal separation (LST) is
dramatically effective in eliminating both aspiration and
GERD in such children ant that QOL can be improved in the
person, parent or guardian by the operation.
In Chiba Children s Hospital LST was performed to children
with severe motor and intellectual disabilities as a treatment
of intractable aspiration, some of them have severe GERD as
well. This report revealed how the surgical treatment, LST
had an effect on GERD in them and aspiration as well.
[METHOD] Forty patients underwent LST in the last 14
years (2000-2013). Retrospectively patients charts and records were reviewed, efficacy of LST being analyzed in
eliminating aspiration or GERD in children by comparing
pre-and postoperative conditions.
[Results] Patients ranged 2 to 19 years of old at their operations. Sixteen of 40 patients suffered from severe GERD, 6 of
them undergone any surgical treatment for their GERD by
pediatric surgeons in advance. The all remaining 10 patients
improved GERD, 2 of them undergoing another operation for
GERD afterward because of their general complications. All
40 patients dramatically experienced an improvement in aspiration.
[Conclusion] LST is dramatically effective in controlling intractable aspiration in the most severe motor and intellectual
disabilities children, also effective in improving GERD, which
leads to making improvements in QOL of the patients, parent or guardian.
Department of Otolaryngology, Kochi Medical School, Japan
Asuka Nagao, Masahiro Komori, Kahori Hrose,
Taisuke Kobayashi, Masamitsu Hyodo
Background: Obstructive sleep apnea syndrome (OSAS) in
children is more severe during rapid eye movement (REM)
sleep than non-REM (NREM) sleep. The lateral position reduces frequency of sleep apnea and snoring is known anecdotally. There are some reports about relation to the positions; the airway patency is better in the lateral position than
in the supine one, and sleep time in the supine position is prolonged after an adenotonsillectomy. However, indication and
evaluation of surgical treatments is based on the total apnea
hypopnea index (AHI). Aims of the study are to clarify discrepancies of frequency of sleep apnea on the REM!
NREM
sleep or the supine!
lateral positions, and efficacy of the adenotonsillectomy procedure.
Methods: Our study included 42 cases who underwent polysomnography (PSG) before and after adenotonsillectomy between August, 2010 and August, 2012 (aged: 1∼14years; 26
male, 16 female). No congenital diseases were identified in
the subjects.
Results: The obstructive AHI improved in the almost cases
significantly(p <0.01∼0.0001) and the improvement was not
relevant to the positions and the sleep stages: pre-!
postoperative obstructive AHIs [number of deteriorated cases]
were 25.3 28.9!
1.1 2.5 [6] on the REM sleep and supine position, 22.9 30.1!
0.6 1.9 [3] on the REM sleep and lateral position, 7.9 13.3!
0.2 0.5 [3] on the NREM sleep and supine position, 6.3 11.1!
0.2 0.5 [3] on the NREM sleep and lateral position. Prevalency of REM and NREM sleep or supine and lateral positions in the total sleep time were not changed. In
terms of discrepancies of obstructive AHIs on sleep stages
or positions, significant differences of preoperative obstructive AHIs were found between REM and NREM sleep in the
supine or lateral position, respectively (p <0.01). On the contrary, in four cases, obstructive AHI on the REM sleep was
0!
h although the time of REM sleep was recorded. There
were not any significant differences between the supine and
lateral positions during REM or NREM sleep, respectively.
The discrepancies disappeared after the operation.
Conclusion: Preoperative obstructive AHIs were quite different between the sleep stages and positions. We thought
that such differences should be appreciated although the
clinical symptoms and background of individual patients are
important for the final decision of the operation. The study
demonstrated that each obstructive AHI was improved, and
determined some cases with sleep apnea during only NREM
sleep occurred.
403
Poster Presentation
E-P11-3
E-P11-4
Evaluation of postoperative improvement of pediatric
obstructive sleep apnea syndrome using pulse oximetry
Airway management of the patient with antley-bixler
syndrome
Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Japan
Eriko Matsuda, Takahiro Fukuhara, Rie Morizane,
Misato Fujiyama, Hiroya Kitano
INTRODUCTION: In Japan, many children with obstructive
sleep apnea syndrome (OSAS) underwent adenotonsillectomy. However, the assessment modality of surgical effect
has not been established. Needless to say, polysomnography
is the gold standard for diagnosing sleep-disordered breathing, but it is not cost-effective to assess all operative patients.
Pulse oximetry is simple and abbreviated evaluation tool, but
there is controversy regarding the reliability of assessment
of pediatric sleep apnea by just pulse oximetry. The aim of
this study is to clarify the utility of pulse oximetry for pediatric OSAS and to evaluate influence of various factors in children.
PATIENTS AND METHODS: In this study, the subjects
were seventy-five children (54 boys and 21 girls; mean age,
4.85 1.94 years old) under twelve years old with OSAS who
underwent adenotonsillectomy. We checked that the adenoids resected absolutely by endoscope during operations.
All patients underwent pulse oximetry examination and we
measured oxgen saturation (SpO2), pulse rate and body motion. We used SpO2 Trend Chart G as analysis software and
analyzed data excluding the artifacts of body motion. Postoperative Oxgen desaturation index of 4% and 3%, mean SpO2
values and lowest overnight SpO2 values were compared
with preoperative data. RESULTS: Six children received
adenotomy, sixty-two children received adenotonsillectomy
and seven children received adenotonsillectomy with laser
turbinate surgery. In all children, we judged the surgical
treatments improved OSAS. However the results of pulse
oximetric examination showed that 52% patients improved
as 4% ODI and 49% patients improved as 3% ODI. The results of postoperative pulse oximetry did not improve in patients treated by laser turbinate surgery and patients who
were examined postoperative evaluation within 4 days.
404
Department of Otolaryngology, Head and Neck Surgery, Hokkaido University, Japan
Hiromitsu Hatakeyama, Kenji Mizoguchi,
Akihiro Homma, Takatsugu Mizumachi,
Satoshi Fukuda, Tomohiro Sakashita
Antley-Bixler syndrome (ABS) was first described in 1975,
and fewer than 50 cases have been reported to date. In addition to brachycephaly, the syndrome is associated with midface hypoplasia, often with choanal stenosis or atresia, bilateral radiohumeral synostosis, multiple joint contractures,
femoral bowing and long bone fractures, pear-shaped nose,
dysplastic ears and, occasionally, urogenital or cardiac defects. Upper airway obstruction is most critical factor for
their survival. The overall prognosis can be favorable with
early and effective prevention of respiratory complications
and early treatment of craniosynostosis.
The case was a female child who was diagnosed with ABS
by the several features and the genetic mutations in the fibroblast growth factor receptor 2. She had severe respiratory distress with lower than 70% oxygen saturation at birth
and intratracheal intubation had been done. Severe airway
stenosis were found at the choana and the pharynx at the
level of base of tongue on the CT images. Malacia of the larynx and trachea were not presented. Tracheostomy could
not be done because of the lower displacement of the larynx.
To keep airway, the silicone nasal airway tube were inserted
to the lower level of base of tongue with expanding choana
using the long nasal speculum under the fiberscope observation. End of the tube need to locate just above the tip of epiglottis to keep airway and to avoid a laryngeal reflex. These
finding support the idea that this type of nasal airway tube is
very uselful for severe upper airway obstruction due to choanal stenosis and midfacial retrusion in the patient with ABS.
Poster Presentation
E-P12-1
E-P12-2
Tracheal regeneration using a collagen vitrigel sponge
scaffold containing basic fibroblast growth factor
Regeneration of tracheal cartilage using bioengineered trachea with autologous chondrocytes
Department of Otolaryngology, Fukushima Medical University, Japan
Depertment of Otolaryngology, Fukushima Medical University School of Medicine, Japan
Akiko Tani, Yasuhiro Tada, Nomoto Mika,
Imaizumi Mitsuyoshi, Nomoto Yukio, Otsuki Koshi,
Omori Koichi
Mika Nomoto, Yukio Nomoto, Yasuhiro Tada,
Akiko Tani, Koichi Omori
Introduction: Our group has had good results in tracheal mucosal regeneration using collagen vitrigel sponge scaffold in
animal model. In this study, collagen vitrigel sponge scaffold
with basic fibroblast growth factor (b-FGF) was fabricated.
Objective: To investigate the effectiveness of this scaffold
and the regenerative process, the tracheal epithelium was
evaluated histologically and morphologically.
Methods: Three types of collagen vitrigel sponge scaffolds
were made, stimultaneously applying no b-FGF, applying 10
ng and 100ng of b-FGF.
At 3, 5, 7, and 14 days after implantation, the tracheae were
extirpated and histologically evaluated. In addition, the regenerative process in the scaffold with 100ng of b-FGF was
evaluated. At 5, 7, and 14 days after implantation, the intraluminal surface of the regenerated tracheae was observed using endoscope. Histological examination of the intraluminal
regenerated trachea was performed using light microscope
and scanning electron microscope.
Results: The mucosal epithelium such as pseudostratified
epithelium and ciliated cells was regenerated earlier in the
scaffolds when b-FGF was applied than when b-FGF was not
applied. The regeneration of the subepithelial layer, infiltration of inflammatory cells and fibroblasts, and angiogenesis
were promoted earlier in the scaffolds with b-FGF application. In the evaluation of the regenerative process, the endoscopic images showed epithelial regeneration at 7 days after
implantation. Scanning electron microscopy images showed
regenerated epithelial cells at 5 and 7 days and ciliated cells
at 14 days after implantation.
Conclusions: Our technique for tracheal reconstruction using
vitrigel collagen-sponge scaffolds with b-FGF application affords a feasible approach for accelerating regeneration of the
intra-luminal surface and subepithelial layer of the regenerated tracheal tissue. An investigation into the horizontal section and luminal area of the regenerated epithelium revealed
that epithelial equality to normal trachea was regenerated in
a rat model with collagen vitrigel scaffold containing b-FGF
at 14 days.
Background
Tracheal prostheses composed of polypropylene and collagen sponge have been used in adults with successful results.
However, this treatment could not be indicated for growing
children because the polypropylene frame does not expand.
Alternatively, a tracheal prosthesis with a cartilaginous
frame could be used in children. In this study, a bioengineered trachea composed of autologous chondrocytes was
developed, and its effect on cartilaginous regeneration was
evaluated by implantation into tracheal defects in rabbits.
Methods
Chondrocytes were harvested from the costal cartilage of a
Japanese white rabbit and seeded into a tracheal prosthesis
composed of polypropylene (the frame) and collagen sponge
(the scaffold). The bioengineered trachea (tracheal prosthesis
with chondrocytes) was implanted into surgically created
tracheal defects of rabbits in the bioengineered group, while
a tracheal prosthesis without chondrocytes was implanted in
the control group.
Results
In the bioengineered group, regenerated cartilaginous tissue
was observed in the bioengineered trachea and the tracheal
cartilage defect had been repaired into a ring-shaped form as
a whole, as indicated by H&E staining and alcian blue staining. In the high-power field, the laminar-regenerated cartilaginous tissue connected to the perichondrium and extended from the edge of the tracheal cartilage. Cartilagespecific findings including interterritorial matrix and territorial matrix were observed. Vasculogenesis was evident in
the regenerated cartilage. In the control group, effective regeneration of cartilage was not observed in the tracheal
prosthesis.
Conclusions
It was confirmed in this study that the implanted chondrocytes proliferated in an appropriate portion of the tracheal
defect and that the partially resected tracheal cartilage was
repaired with regenerated cartilaginous tissue into a ringshaped form as a whole. These results demonstrate the feasibility of cartilaginous regeneration using a bioengineered
trachea with autologous chondrocytes.
405
Poster Presentation
E-P12-3
E-P12-4
Simulation-based training for rigid bronchoscopy
Swallowing training methods with immediate effect
and simple
School of Health Science, Tottori University, Japan1), Division
of Otolaryngology, Head and Neck Surgery2)
Hideyuki Kataoka1), Takahiro Fukuhara2),
Kazunori Fujiwara2), Hiroya Kitano2)
Background: The ability to acquire surgical skills requires
consistent practice. Real live operation would be defficult for
surgical training because of ethical issues. Simulation model
is a safe and controlled environment for surgical trainees, especially novice surgeons. The aim of the present study was
to describe our experience with the surgical training for
rigid bronchoscopy. Few studies focused on advanced skills
such as rigid bronchoscopy. Simulation training may decreases patient risks and enables deliberate structuring of instruction including exposure to rare events such as foreign
body aspiration.
Methods: The rigid bronchoscopy was the main technique
used in the removal of foreign body. The simulation model
for the treatment of foreign body aspiration was Bronchokids (Karl Storz) and rigid bronchoscopes with telescopic
optical system. Teaching a technical skill such as rigid bronchoscopy is challenging, as it requires specific knowledge of
upper airway anatomy of child.
Results: Simulation-based training for rigid bronchoscopy allows the novice surgeon more experience to maneuver while
doing the endotrachial work. Educational study of rigid bronchoscope has specifically focused on improving skill acquisition necessary to remove of foreign body. Simulation training
was associated with large benefits on skills and behaviors to
performe by experienced and safe methods.
Conclusion: The use of model training improved the operative performance of novice surgeons during removal of foreign body. Surgeons need to be able to master rigid bronchoscopic technical skills and improves operative outcome.
406
Department of Otolaryngology, Fujita Health University, Japan
Yoshihiro Iwata, Nagasaka Satoshi, Okada Tatuyoshi,
Katou Hisayuki, Sakurai Kazuo, Naitou Kensei
Background: In Japan, elderly people are growing today.
People with mild dysphagia along with it are also increasing.
We do not feel examination and treatment required for these
people to be sufficient. I think an effective method of treatment is needed for this dysphagia. We have developed swallowing training procedures that have an immediate effect. It
can also be carried out on its own.
Method: We were training in the following ways. Subjects
trained to sit in a chair, the therapist to hold in their hands
the chin tip. And then, lifting on the strong hand holding the
chin, subject s trained hauling chin his therapist. I put a load
of isometric contraction strongest muscle in the neck (Fig).
Time of contraction of the muscle for a few seconds. It was
carried out three times in a row this. We evaluated by (VF)
fluoroscopy swallowing.
Result: We conducted a VF test before and after you do the
training for 70 s men. I was compared with travel time of
barium in the upper esophageal entrance from the pharynx.
Before the training, it was necessary 3.44 seconds on average
to the transfer time. After training, it was necessary 1.94 seconds average transfer time. Time of transfer is shortened. In
the second phase swallowing, elevation of the larynx is
changed to soon. After training, the position of the hyoid
bone has moved on and before.
Conclusion: I think the consequences of the muscles of the
neck are relaxed under the influence of contraction isometric
strong.
Without the need for special tools or place, this training procedure can be carried out easily. I also have a sufficient effect.
Poster Presentation
E-P12-5
E-P13-1
Withdrawn
Analysis of oral ingestion after surgical closure of the
larynx: Prediction from pre-operative state
Department of Otorhinolaryngology-Head & Neck Surgery,
National Center for Global Health and Medicine, Japan
Shingo Takano, Niro Tayama
Objective: Surgical closure of the larynx (SCL) is a method to
prevent aspiration that sacrifices vocal function. Many patients can expect a return to oral ingestion after SCL. The
aim of this study is to be able to make a prediction of postoperative oral ingestion ability from pre-operative state.
Methods: We performed 46 cases of surgical closure using
our original method in 2 institutions from 2003 to 2013. The
patients who had experienced repeated aspiration pneumonia, and had lost vocal communication ability were considered as candidates for SCL. Before operation, we checked
swallowing function using videofluorography (VF) in all patients except severe condition or disability to take seating
position. We analyzed the following data from VF video retrospectively: duration of oral stage of swallowing; rate of
pharyngeal residue (%); time until the next swallowing starts.
Results: No leakage from the closure was identified clinically
except one cerebral paralysis case that had very inclined
neck. That was very minor leakage so aspiration pneumonia
was prevented in all cases after operation. All 3 items from
VF video had statistically significance between measured
data and conditions of oral ingestion. The ability of postoperative oral ingestion was high in the situation that duration of oral stage of swallowing was short; rate of pharyngeal
residue was small; and time until the next swallowing start
was short.
Conclusions: Prevention of aspiration pneumonia is very important in medical managementand we believe that our
method offers a good means by which to achieve this goal.
Besides, many cases could regain oral ingestion after this operation. It is very useful to be able to make a prediction of
post-operative oral ingestion ability for the propagation of
this method.
407
Poster Presentation
E-P13-2
E-P13-3
Analysis of postoperative swallowing after esophagectomy for esophageal cancer
Prognostic indicators for dysphagia in hospitalized patients
Department of Otorhinolaryngology-Head & Neck surgery,
Kansai Medical University, Japan1), Department of Gastroenterological Surgery, Kansai Medical University, Japan2)
Division of Otorhinolaryngology Head & Neck Surgery, Faculty of Medical Science, University of Fukui, Japan
Makoto Miyamoto1), Eri Miyata1), Sakagami Tomofumi1),
Masao Yagi1), Koichi Tomoda1), Taku Michiura2),
Junichi Fukui2)
We examined factors contributing to oral intake and hospitalization after esophagectomy for esophageal cancer. From
April 2007 to March 2012, 177 patients underwent
esophagectomy in our hospital. Out of 177 patients, 103 patients underwent right transthoracic subtotal esophagectomy, lymphadenectomy (3-field dissection) and gastric tube
reconstruction via postmediastinal route. We analysed 94 patients who evaluated the vocal fold movement by laryngeal
fiberscopy after esophagectomy, except 9 patients who recovered vocal fold movement in relatively short period.
We analysed the relationship between preoperative patient s
status, operative factors, postoperative complications and
the onset of oral intake.
Postoperative recurrent nerve paralysis did not affect the
onset of oral intake. Patients with continuous recurrent
nerve paralysis and!
or with lower levels of a preoperative
serum albumin had longer length of hospitalization than patients with transient recurrent nerve paralysis and with normal levels of preoperative serum albmin. The cases intubated longer than two days after operation were longer
length of hospital stay than the cases with one day intubation. Among postoperative complications, failure of the sutures and postoperative pneumonia affected the onset of oral
intake.
The results indicated that the postoperative complications
including sutures leakage and pneumonia affected the onset
of or oral intake after surgery and the length of hospitalization more than the recurrent nerve paralysis.
408
Akihiro Kojima, Yumi Ito, Masafumi Kanno,
Shigeharu Fujieda
(Objective)
Predicting whether dysphagia will resolve is difficult, but is
obviously important for patients, their families and physicians. This study retrospectively evaluated potential prognostic indicators for dysphagia in order to examine the feasibility of predicting the outcome.
(Methods)
A total of 123 patients who received initial treatment for
dysphagia between April 2008 and March 2010 were reviewed. They included 63 men and 60 women, with a mean
age of 81.4 years. All of the patients underwent physical examination and video-endoscopy (VE) at the initial assessment, and video-fluorography (VF) was also done if necessary. We used the Food intake level scale (FILS) to classify
the severity of dysphagia as follows: No oral intake (FILS
score: 1-3), oral intake and alternative nutrition (FILS score:
4-6), and oral intake alone (FILS score: 7-10). The patient s
age, primary disease, cognitive ability, and general condition
were evaluated as potential factors associated with the severity of dysphagia. Each patient underwent assessment
every 2 weeks to evaluate the progress of their dysphagia.
(Results)
At the initial examination forty-six were classified as no oral
intake (FILS score: 1-3) and subsequently showed improvement to oral intake and alternative nutrition (FILS score: 46) or oral intake alone (FILS score: 7-10). They were compared with 43 patients who were also no oral intake at the
second examination after training in swallowing. The combination of stroke and cognitive dysfunction showed a sensitivity of 75.9% (22!
29) and specificity of 78.3% (18!
23) for predicting no improvement of dysphagia, and was a statistically
significant parameter. The presence of disuse syndrome
showed a sensitivity of 66.0% (31!
47) and specificity of 71.4%
(30!
42) for predicting no improvement of dysphagia, and this
was also a significant parameter.
(Conclusion)
The results of this study suggest that a combination of factors other than stroke, including cognitive dysfunction and a
decrease of activity of daily living (ADL), influence the outcome of dysphagia. It is not rare for patients who resume
oral intake to be readmitted within a year for symptoms
such as fever. Therefore, effective rehabilitation programs
should be developed for the common disabilities and impairments of elderly patients such as dysphagia.
Poster Presentation
E-P13-4
E-P14-1
A simple evaluation method for videofluorography following treatment for head and neck cancer
Evaluation of secondary shunt procedure for alaryngeal patients on an outpatient clinic
Department of Otolaryngology, Nagoya University School of
Medicine, Japan
Yasushi Fujimoto, Kikuko Ozawa, Ken Kato,
Takashi Maruo, Mariko Shimono, Atsushi Suzuki
Purpose: Although the modified barium swallow study is the
standard form of videofluorographic examination, appropriate scoring of its various evaluation items requires training
and experience. Prior to detailed investigation of its use, the
following are first required in clinical settings: 1) real-time
evaluation, and 2) risk assessment. The purpose of this study
is to create a simple evaluation method that enables realtime evaluation.
Materials and Methods: The subjects were 46 patients with
advanced oral, oropharyngeal, laryngeal, or hypopharyngeal
cancer who had undergone chemoradiotherapy (n=21) or
larynx-preserving surgery (n=25). Videofluorography after
surgery or at completion of radiotherapy and after improvement of swallowing function were analyzed (total, n=94). Using the findings obtained from the initial swallow (5 ml of
40% barium), oropharyngeal swallow efficiency (OPSE), degree of aspiration and presence or absence of silent aspiration (As), and degree of pharyngeal residue (R) were evaluated. Multiple regression analysis was performed using As
and R as independent variables and the measured OPSE as
the dependent variable (standard), and scores were obtained
by rounding the regression coefficients for As and R to the
nearest integer.
Results: A scoring system that combines the scores on a
four-point scale for As (in order of increasing degree, 4, 3, 1, 0
points) and R (6, 3, 2, 1 points) was obtained. A high correlation coefficient (0.733) was observed between the scores and
the measured OPSE.
Conclusion: This simple evaluation method evaluates swallow efficiency and risk by focusing only on two (degree of aspiration and pharyngeal residue) of the various evaluation
items of videofluorography.
Department of Otolaryngology, Takii Hospital, Kansai Medical
University, Japan1), Department of Otolaryngology, Head and
Neck Surgery, Hirakata Hospital, Kansai Medical University,
Japan2)
Hiroshi Iwai1), Masaya Konisihi1), Naomi Ando1),
Susumu Baba1), Makoto Miyamoto2), Koichi Tomoda2)
The shunt procedure used for laryngectomized patients undergoing secondary tracheo-esophageal or tracheo-neoesophageal
(reconstructed with flap) puncture is inconvenient and
causes stress to the patients. In order to overcome these
problems we developed a novel surgical shunt procedure
technique using an indwelling voice prosthesis that does not
require esophagotomy or general anesthesia and can be performed in an outpatient clinic.
In this procedure, a shunt is created using a pair of nasal forceps with the patients seated. An endoscope with biopsy forceps is used to insert the voice prosthesis. The puncture is
completed within 20 min after inducing local anesthesia. Neither
the technique itself nor the time taken to complete the procedure differs for tracheo-esophageal or tracheo-neoesophageal
shunting.
In this study, we aimed to examine complications of the procedure and also investigated indications of this secondary
shunting to alaryngeal patients in view of location of the
esophagus, air insufflation test, postoperative (chemo)radiation, the size of the tracheostoma, and so on.
Figure: A case of contraindication of secondary shunting because of location of the esophagus, which contacts with the
pleura and does not exit behind the trachea.
409
Poster Presentation
E-P14-2
E-P14-3
Too much fat in the vocal folds
Analysis of high-speed imaging of vocal folds-A study
of the effects of shooting speed has on the image
analysis-
Department of Otorhinolaryngology, Tokai Voice Clinic Center, Tokai University School of Medicine, Japan1), Department
of Otorhinolaryngology, Tokai University School of Medicine,
Japan2)
Etsuyo Tamura1), Hiroyuki Fukuda1), Yoshihiro Wada1),
Shinya Okada2), Masato Shibuya2), Masahiro Iida2)
Introduction: Vocal fold augmentation with autologous fat
has been used increasingly as vocal rehabilitation in patients
with deficient glottal closure. In this technique, the surgeon
overcorrects by injecting at least 30-40% more fat than
needed to achieve glottis closure to compensate for anticipated fat reabsorption.We have treated one patient who required excision of fat from the vocal folds to obtain good vocal fold wave motion during phonation and improved voice.
Case Report: A 26-year-old woman underwent autologous fat
injections bilaterally three times from 2008 to2009. Postoperatively, her hoarseness did not improve sufficiently, which
prompted a type 3 thyroplasty in 2010. This intervention,
however, further aggravated the voice. Buccal fat injection
for the dysphonia was being considered as the next measure
when the patient visited our center. Almost no wave motion
of the bulging vocal folds were observed, especially on the
left, and the voice was breathy. These findings were both attributable to the excessively expanded vocal fold due to too
much fat injection. A CT of the neck was performed, and fat
was seen in both true vocal folds, more so on the left.
In January 2012, the previous injected fat was exposed and
dissected from the vocal folds. A month after fat excision, a
significant improvement was seen in the voice and vocal
folds wave motion during phonation.
Conclusion:Although autologous fat is a safe injection material, it may cause worsening of the voice when excessive
amounts of fat are injected.
410
Department of Otolaryngology-Head and Neck Surgery, Nihon University, Japan
Tomoyuki Takane, Kiyoshi Makiyama,
Hiroumi Matsuzaki, Hirotaka Suzuki, Ryoji Hirai
Background) Vocal cord high-speed imaging is an examination to capture the real image of the vocal cord vibration at a
shooting speed that far exceeds the frequency of the vocal
cords. Acquired videos can be used to quantify various parameters of the vocal vibration in combination with the video
analysis technique. It is considered that the parameters are
normalized by quantification if videos taken under the same
conditions, the comparison of different cases and determination of treatment becomes easy. However, since high-speed
imaging has not been defined for the shooting speed at the
moment, facilities differ from one another in the shooting
speed depending on cameras they use.It is easy to understand from the principle that the shooting speed influences
analysis results. Therefore, we studied effects of the shooting
speed on analysis results using a digital CCD camera that
could change shooting speeds in a range from 1000 to 8000 f!
s.
Method) We shot the vocal cord vibration in four cases, a
subject with no phonetic disorder, vocal cord polyp, laryngeal cancer, and vocal cord atrophy, respectively at a shooting speed of 1000 f!
s, 2000 f!
s, 4000 f!
s, and 8000 f!
s. We performed glottal area waveform analysis, kymograph edge
analysis and phase shift analysis on approximately onesecond video clips of the regular phonation region.
Result) Analysis results differed depending on the shooting
speed even in the same subject. And the shooting speed influenced differently between parameters. Nevertheless, any
shooting speed could identify the characteristics of individual cases.
Conclusion) Vocal cord high-speed imaging is a relatively
new examination method, and its shooting speed and analytical method has not been standardized. It is, however, a very
useful examination method to characterize vocal vibrations,
although results cannot simply be compared between facilities because of camera specifications dependent differences
in analysis results.
Poster Presentation
E-P14-4
E-P15-1
3D measurement of paralyzed larynx using cone beam
CT accuracy
A study of muscle atrophy after denervation in the rat
laryngeal muscle
Department of Otolaryngology, Kawasaki Municipal Ida Hospital, Japan1), Department of Otolaryngology-Head & Neck
Surgery, Keio University School of Medicine, Japan2), Department of Radiology, Keio University School of Medicine, Japan3)
Department of Otolaryngology, Ehime University School of
Medicine, Japan
Haruna Yabe1), Koichiro Saito2), Kosuke Uno2),
Takeyuki Kono2), Suketaka Momoshima3), Kaoru Ogawa2)
Introduction: Skeletal muscle atrophy is caused by aging,
denervation and diseases and severely decreases the quality
of life. One of the major protein degradation pathways, ubiquitinproteasome system is activated during muscle atrophy and
variably contributes to the loss of muscle mass. This degradation system is controlled by a transcription dependent program.Recently, it is revealed that a transcription factor such
as FOXO and PGC-1α greatly participates in restraint and
promotion of the skeletal muscle atrophy. Forkhead box O
(FOXO) is to promote transcription of the muscle-specific
ubiquitin ligase, and muscle atrophy is progressed by FOXO
3a especially.
On the other hand, Peroxisome proliferator γ activated receptor g coactivator-1α (PGC-1α) participates in metabolism
of the mitochondria and works as the muscle atrophy restraint. However, the detailed molecular mechanisms on the
intrinsic laryngeal muscle are not clearly understood. Therefore we decided to elucidate the molecular mechanism in the
intrinsic laryngeal muscle atrophy.
Materials and Methods: Thirty-six Wistar rats were euthanized 4, 8 and 12 weeks after left recurrent laryngeal nerve
resection. We extracted from bilateral thyroarytenoid (TA),
posterior cricoarytenoid (PCA) muscles and extensor digitorum longus muscle from lower limbs as control in rats. We
quantitatively evaluated expression of FOXO3a, phosphorylated FOXO3a and PGC-1α using Western blotting. In contrast, the entire muscle cross-sectional area (CSA), muscle fiber CSA and number of muscle fibers were evaluated using
hematoxylin-eosin staining. Changes after denervation were
evaluated by comparing the treated (T) and untreated (U)
sides (T!
U ratio).
Result: The expression of FOXO3a increased significantly
between 167 and 185% after 12 weeks. The expression of
PGC-1α increased significantly 170 and 180% after 12 weeks.
The expression of phosphorylated FOXO3a decreased significantly between 72 and 86% after 12 weeks. But the differences were not significant between TA and PCA muscle.
As for the average T!
U ratio for the entire muscle CSA of
TA and PCA ranged between 42.2% and 63.1% significantly,
and the differences were significant between TA and PCA
muscle after 12 weeks. Similarly, the T!
U ratios for the muscle fiber CSA of TA and PCA ranged between 38.7% and
45.7% significantly. However the number of muscle of fibers
TA and PCA were not significant.
Conclusion: The molecular mechanism of muscle atrophy existed between intrinsic laryngeal muscles equally. The entire
muscle CSA of PCA reduced compared with TA muscle significantly after denervation.
Background:
Cone beam CT technology (CBCT) was developed for the office-based
quick and precise 3D visualization of maxillofacial region at relatively
modest cost. This technology applies cone beam x-rays to the head and
neck, providing 2D and 3D images. CBCT requires short scanning time
of less than 10 seconds and provides isotropic 3D image with significantly high resolution. In addition, this novel device has several potential advantages such as lower cost compared to conventional CT or MRI
and the ability to conduct scans with the patient in the sitting position.
Quick 3D visualization utilizing this novel device could provide critical
information for the better understanding of glottal insufficiency. In this
study, we measured the shape!size of paralyzed larynx in Japanese patients with multiple parameters using CBCT to obtain multiple parameters critical for diagnosing and treating patients with laryngeal paralyses.
Methods:
Eighty-nine Japanese patients referred to our institution with unilateral
vocal fold paralysis from April 2007 to November 2011 were incorporated in this case series study. The subjects consisted of 54 males and
35 females, with the mean age of 59.9 years. Laryngeal CBCT images
were taken in 2 conditions: 1) patients sitting relaxed (R image), and 2)
patients applying pressure at their diaphragms (P image). MPR images
and reconstructed endo-laryngeal 3D image of a patient with left vocal
fold paralysis are shown in the Figure. Lengths of bilateral vocal folds,
bilateral horizontal glottal angles and sizes of gaps from a median plane
of each larynx were measured in R images. Vertical gaps of bilateral vocal folds were measured in P images.
Results:
Mean lengths of nondiseased vocal folds (males, 18.5mm; females, 12.9
mm) were significantly longer compared with diseased side (males, 17.7
mm; females, 12.4mm) either in males (p=0.011) and females (p=0.001).
Glottal angles were significantly wider in nondiseased side (16.1̊) compared with diseased side (9.4̊, p=0.001). Vertical gaps were normalized
with the lengths of nondiseased vocal folds with mean value of 0.057.
Conclusions:
Our study showed the first correct measurement of the shape!size of
paralyzed larynx in live Japanese patients. These data will contribute to
the improvement of diagnosis and surgical procedures for the patients
with laryngeal paralysis in the future.
Hirofumi Sei, Aki Taguchi, Naoya Nishida, Kiyofumi Gyo
411
Poster Presentation
E-P15-2
E-P15-3
Electrical stimulation with an implanted device for vocal fold adduction in unilateral paralyzed larynx
The role of the cricopharyngeus muscle in pitch control
Department of Otolaryngology-Head Neck Surgery, Asahikawa Medical University, Japan
Kenichiro Nomura, Akihiro Katada, Isamu Kunibe,
Yasuaki Harabuchi
The aim of this study was to create an implantable device
with a suitable electrode, and to examine the feasibility of
electrical stimulation to produce vocal fold adduction in unilateral paralyzed larynx.
Unilateral vocal fold paralysis (UVFP) causes breathy
hoarseness because of the glottal gap during phonation. To
offset this gap medialization procedures, such as type I thyroplasty, are currently popular treatments for UVFP. However, because these treatments do not restore paralyzed vocal fold, patients do not recovery completely normal voice as
before. A more physiologic approach to restore the paralyzed vocal fold involves functional electrical stimulation
(FES) of the intrinsic muscles of the larynx. To apply FES to
UVFP could resolve underlying problems that arise because
medialization procedures are static. The first problem is that
the vocal fold muscles do not contract during phonation. The
other is that it is difficult to fine-tune the already medialized
vocal fold. FES could offer vocal-fold adduction with muscle
contractions, and also fine-tune the vocal-fold position by altering stimuli parameters. Essential part of FES for clinical
application is to use an appropriate implantable device with
a suitable size electrode for tiny laryngeal muscles. We previously demonstrated a newly created electrode for the thyroarytenoid (TA) muscle. The aim of this study was to create
a suitable implantable device for TA muscle stimulation, and
to examine the feasibility of TA stimulation to produce vocal
fold adduction in anesthetized animals with the paralyzed
larynx. Canines were used in this study. An electrode array
was implanted into thyroplasty window to stimulate TA
muscle. Stimulus frequency was fixed at 40 Hz. Vocal fold angle from anterior commissure to vocal process resulting
from TA stimulation was measured endoscopically in the
anesthetized animal. This study demonstrated that TA
stimulation with new created electrode could produce optimal glottal closure. However, reinnervation was desired for
optimal glottal closure.
412
Otolaryngology-HNS, Chonbuk National University, Korea1),
Otolaryngology-HNS, Chonbuk national University, Korea, Republic of (South Korea)2)
Ki Hwan Hong1), Yunsu Yang2)
Electromyographic studies of the cricopharyngeus muscle
using hooked wire electrodes were performed in the thyroidectomized patients. The shape of cricoid cartilage and soft
tissue thickness of postcricoid area were evaluated using
conventional neck lateral films during pitch elevation and
pitch lowering. The activity of the cricopharyngeus muscle
simultaneously activated in the initial task of speech and continuously activated. Its activity lowered in the interrogative
stress contrast of sentence terminal and elevated in the pitch
lowered contrast of sentence terminal. On the radiologic findings the cricoid cartilage was tilt backward during high
pitched phonation and tilt forward during low pitched phonation. The soft tissue thickness of postcricoid area was thicker
in the low pitch than high pitch. During low pitched the cricoid cartilage paralleled along the vertebral column. This result suggested that the bulging of cricopharyngeus muscle
by its contraction induced the postcricoid area thickened,
and a pressure exerted on the cricoid cartilage anteriorly.
This contraction of cricopharyngeus muscle may result in
shortening the vocal fold and lowering the pitch.