Minoru Endo

Antiemetic therapy of fosaprepitant, palonosetron, and dexamethasone combined with cisplatin-based chemotherapy for head and neck carcinomas

Abstract Conclusion: Concomitant antiemetic therapy comprising fosaprepitant, palonosetron, and dexamethasone is effective for head and neck carcinoma. Objective: A patient diary was constructed to determine the effectiveness of concomitant antiemetic therapy with a neurokinin-1 receptor antagonist (fosaprepitant), 5-hydroxytryptamine receptor antagonist (palonosetron), and dexamethasone in accordance with guidelines. Methods: Subjects comprised 41 patients who received 71 courses of chemotherapy, along with fosaprepitant, palonosetron, and dexamethasone. A patient diary was compiled concerning the presence/absence of vomiting, vomiting episodes, presence/absence of rescue therapy, food intake, presence/absence of nausea, and general condition. Results: The frequency of the primary end point of complete response in the overall phase was 69.0%. The proportion of patients with no vomiting in the overall phase was 90.1%. In the acute phase, the proportion of no nausea and slight nausea together was 91.5%, no change in and slightly reduced food intake together was 87.3%, and the proportion of good general condition and relatively good general condition was 85.9%. In the delayed phase, the proportion of no nausea and slight nausea together was 56.3%, no change in and slightly reduced food intake together was 43.7%, and the proportion of good general condition and relatively good general condition together was 53.5%.

A Case of Giant Osteoma in the Middle Turbinate of a Child

Only seven cases of osteoma arising in the middle turbinate have been reported to date. We report the eighth case, involving osteoma in the middle turbinate of a child. This young boy was initially examined at the age of nine for the main complaint of nasal obstruction. Although a large osteoma with a maximum diameter of 30 mm was observed on computed tomography (CT), the patient was only observed because of the wishes of the family. At 13 years, he was again examined, as a result of worsening of the nasal obstruction. CT revealed that the osteoma had enlarged to a maximum diameter of 41 mm. Endoscopic surgery was attempted, but because of difficulties, the osteoma instead had to be removed under direct vision via a gingival incision. The final pathological diagnosis was osteoid osteoma. The nasal obstruction disappeared following surgery, with no recurrence after more than 12 months postoperatively.

A case report of malignant melanoma of the sphenoid sinus.

Malignant melanoma of the sphenoid sinus is a very rare disease, and only 6 cases have previously been reported. The present case involved a 74-year-old woman who was examined for visual disturbance of the left eye. Computed tomography revealed a soft tissue shadow, but only mucosal hypertrophy was found on opening the sphenoid sinus under general anesthesia. One month postoperatively, visual disturbance of the right eye and paresis of cranial nerve III appeared. Malignant melanoma was diagnosed from biopsy. Multiple bone metastases were identified, but the patient declined active treatment. As a result, palliative care was provided and she died 3 months later. When there is no improvement in postoperative visual acuity as in this case, in consideration of the possibility of neoplastic lesions, rigorous followup including monitoring for neurological symptoms is warranted.

Joint Use of Skull Base Surgery in a Case of Pediatric Parotid Gland Carcinoma

Parotid gland carcinoma is extremely rare in children. We report a case of pediatric parotid gland carcinoma with extensive infiltration into surrounding tissues including the skin and temporomandibular joint capsule at initial examination. Total resection of the parotid gland was conducted together with skull base surgery and mandibular dissection. The patient was a 14-year-old girl. In addition to the skin and temporomandibular joint, infiltration into the anterior wall of the external auditory meatus and masseter muscle was also seen, and T4N0M0 stage IV parotid carcinoma was diagnosed. Skin was resected together with the pinna, and temporal craniotomy and skull base surgery were performed to resect the temporomandibular joint capsule and external auditory meatus en bloc, and mandible dissection was conducted. Facial nerves were resected at the same time. Level I to level IV neck dissection was also conducted. A latissimus dorsi myocutaneous flap was used for reconstruction. The postoperative permanent pathology diagnosis was high-grade mucoepidermoid carcinoma with a low-grade component. Postoperatively, radiotherapy at 50 Gy alone has been conducted, with no recurrence or metastasis observed for over 4 years.

Deep neck cellulitis: limitations of conservative treatment with antibiotics

Abstract Conclusion: When the parapharyngeal space is infected, concurrent involvement of other spaces is likely, and involvement of multiple deep neck spaces is a key risk factor for abscess formation. Objectives: Deep neck infection is treated with antibiotics when abscesses have not yet been formed. However, in some cases, abscesses will form later and surgical drainage is warranted. This study retrospectively examined which cases were less likely to achieve cure, to clarify the limitations of conservative treatment for deep neck cellulitis. Patients and methods: Subjects comprised 19 patients with deep neck cellulitis who initially underwent conservative treatment with antibiotics. Patients were divided into two groups: Group A (n = 7), patients who recovered by conservative treatment; and Group B (n = 12), patients who did not recover and underwent surgical drainage. Age, state of DM control, etiology, treatment, spaces infected, and duration of hospitalization were investigated. Results: The number of infected spaces was one in all Group A patients, whereas Group B showed multiple infected spaces in all except two cases. In particular, among the 10 cases with parapharyngeal space infection, eight (80%) showed multiple lesions.

Secondary insertion of Provox®2 using an endotracheal tube

Abstract Conclusion: A procedure with no exploratory puncture using an endotracheal tube, sharp-tipped trocar, flexible fiberscope, and flexible guidewire is useful for inserting the Provox®2 prosthesis. Objectives: The purpose of the present study was to examine the necessity of exploratory puncture in consideration of operating time, complications, and voice rehabilitation. Methods: Insertion of the Provox®2 was conducted using an endotracheal tube, sharp-tipped trocar, flexible fiberscope, and flexible guidewire under general anesthesia. This was performed in conjunction with exploratory puncture in the first 7 patients, and without exploratory puncture in the following 15 patients. Results: Operating time was 10 min in the group with exploratory puncture and 6 min in the group without exploratory puncture. Although a shorter size had to be substituted in one patient without exploratory puncture on the day following the procedure due to difficulty with eating, no complications due to the procedure were observed in any patients. Speech production was possible in all patients on the following day.

Decision making for position-dependent obstructive sleep apnea syndrome on the basis of patient information and physical examinations of the upper airway, acquired on an outpatient basis

Abstract Conclusions: Patients with body mass index (BMI) < 25 kg/m2 and obstructive sleep apnea syndrome (OSAS) are highly suspicious for position-dependent OSAS. Diagnosis of position-dependent/position-independent OSAS can be difficult in patients satisfying both ‘BMI >25 kg/m2’ and ‘any of tongue enlargement (TE), palatine tonsil hypertrophy (PTH) and obstruction by Muller’s maneuver (OMM)’. Polysomnography is warranted in such patients. Objectives: The objective was to retrospectively elucidate criteria for differentiating position-dependent OSAS on the basis of patient information and physical examinations of the upper airway obtainable in clinics. Methods: The 643 patients were categorized as positional patients (PPs) or non-positional patients (NPPs). The patient background factors examined were sex, age, BMI, and hypertension. TE, PTH, pharyngeal tonsil hypertrophy, and OMM were evaluated. Cross-validation was performed using even-numbered registrations as the training set group (Group A) and odd-numbered registrations as the test case group (Group B). Results: In Group A, patients with BMI <25 kg/m2 were clearly more frequent among PP than among NPP. In Group A with BMI ≥25 kg/m2, significant differences were found for TE, PTH and OMM. Significant differences were found between 0 and 1/2/3 for number of factors. Results generated from Group A were validated in Group B.

Application of cervical epidural anesthesia in patients with head and neck carcinoma

In head and neck carcinoma surgery, we often encounter patients for whom there is high risk in operations under general anesthesia (GA) with artificial ventilation management, such as elderly patients or those with comorbidities or impaired organ function. Three patients with head and neck carcinoma for whom risks were high under general anesthesia underwent surgery under cervical epidural anesthesia (CEA). The first case is 67-year-old male with cT2N3M0 laryngeal carcinoma. The patient had several medical history such as angina pectoris, renal impairment developed following cisplatin administration and combined ventilator impairment. Right neck dissection was performed (Level I–IV) under CEA. A decrease in blood pressure was observed during surgery, but was controlled with a small dose of vasopressor and fluid replenishment. The second case is 83-year-old female with cT4aN0M0 submandibular gland carcinoma. She had a history of chronic thoracic empyema and severe respiratory dysfunction was observed. Right submandibular gland carcinoma resection and neck dissection (Level I) were performed under CEA. As respiratory depression occurred following anesthesia induction, tracheotomy was performed and artificial ventilation management was still required after surgery had been completed. The third case is 87-year-old male with rT2N0M0 laryngeal carcinoma. Total laryngectomy was performed under CEA. In Case 2, other than the respiratory problems, no other complications were observed during or after surgery. Operation time and amount of hemorrhage were again comparable to those for surgery under GA. For patients at high risk under GA or with systemic diseases or impaired organ function, CEA represents a therapeutic option.

Prospective Randomized Trial on Postoperative Administration of Diet Containing Eicosapentaenoic Acid, Docosahexaenoic Acid, Gamma-linolenic Acid, and Antioxidants in Head and Neck Cancer Surgery Patients with Free-flap Reconstruction.

OBJECTIVES The purpose of this prospective, randomized study was to evaluate the effects of a diet containing eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), gamma-linolenic acid (GLA), and antioxidants in head and neck cancer surgery patients with free-flap reconstruction. METHODS In this randomized, prospective study, 62 patients with head and neck cancers were assigned to receive a general control diet (Ensure® H; Abbott Japan, Tokyo, Japan) or the study diet (Oxepa®; Abbott Japan) containing EPA, DHA, GLA, and antioxidants (eg vitamins A, E, and C). The primary assessment item was the degree of postoperative inflammation, as assessed by measuring maximum body temperature and levels of C-reactive protein (CRP) and procalcitonin from the day of surgery to postoperative day 8. Secondary assessment items were lengths of stays in the intensive care unit (ICU) and hospital. RESULTS The control diet group (n = 32) and study diet group (n = 30) showed no significant difference in energy administered through diet. No significant differences in the parameters of the primary assessment item were noted. Length of stay in the ICU was significantly shorter for the control diet group than for the study diet group (P = 0.011). No significant difference in duration of hospitalization was seen between groups. CONCLUSION No usefulness of a diet containing EPA, DHA, GLA, and antioxidants was demonstrated.

Usefulness of thoracic duct clipping in thoracoscopic surgery for chylous fistula occurring after neck dissection

Chylous fistula is a rare complication after neck dissection. No methods of treatment have been established and conservative treatment is problematic in many cases. The present case report concerns a 79-year-old man in whom we performed total pharyngolaryngectomy, bilateral neck dissection, and free jejunum transfer for stage II hypopharyngeal cancer. On day 5 following surgery, chylous fistula was observed in the left neck. As no improvement was seen with conservative therapy comprising a low-fat diet and octreotide, we performed thoracoscopic thoracic duct clipping on day 28 following surgery. Directly after clipping, chylous leakage stopped. Oral food ingestion was resumed the following day and the patient was discharged within a week. In view of its low invasiveness and few complications, thoracoscopic thoracic duct clipping may offer a good therapeutic option for chylous fistula.