Shoko Inaki

Esophageal web in plummer-vinson syndrome†

In Plummer‐Vinson syndrome, esophagography often reveals a web at the anterior wall of the cervical esophagus. The pathogenesis of the esophageal web and the cause of dysphagia in this syndrome were investigated radiographically, endoscopically, manometrically, and histologically. It was considered that the web seen in the esophagogram may have been formed due to the restriction of dilation of the esophageal wall, which results from repetitive inflammation and the subsequent healing process. Dysphagia in this syndrome may be explained by a decrease in swallowing power. Iron deficiency anemia may play the main role in the above histological changes and the resulting decrease in swallowing power.

Swallowing function following hypopharyngeal reconstruction with the pectoralis major musculocutaneous flap.

Swallowing function was studied in three patients following the pectoralis major musculocutaneous reconstruction of the hypopharynx and cervical esophagus after extensive resection for hypopharyngeal cancer. Fluoroscopy and endoscopy revealed the formation of a sphincter-like ring at the proximal end of the remaining intact esophagus. This ring may act to prevent reflux from the lower esophagus, although its sphincteric power is weak. Manometric testing showed that no swallowing pressure was produced in the reconstructed gullet; therefore, bolus propulsion at the pharyngeal stage occurs mainly by gravity. Follow-up studies on swallowing indicate a minimum length of the suture line of 11 cm in order to prevent esophageal stenosis due to anastomotic stricture at the distal mucocutaneous junction.

Bilateral Gradenigo's Syndrome; A Case Report.

Gradenigos syndrome was diagnosed in a 5-year-old male with bilateral acute otitis media, paralysis of both abducens nerves and bilateral irritation of the trigeminal nerves. After myringotomy and administration of antibiotics, his tympanic membrance became normal, and the bilateral trigeminal nerve irritation disappeared, but residual mastoiditis was revealed by X-ray examination. Right extended mastoidectomy was performed including removal of the bony sinus plate on Mar. 2, 1990. Although bilateral abducens palsy improved immediately, serological findings and double vision deteriorated again 10 days after the operation. Reexploration was done on Mar. 16, 1990. Residual inflammatory changes in the petrous apex were eradicated, especially around the lateral sinus and anterior to the superior semicircular canal through the petrous apex. An extradural abscess was found at the petrous apex. The left trigeminal nerve irritation and the left abducens paralysis was attributed to the right petrositis because bilateral abducens nerve function recovered completely after the second operation on the right temporal bone. Since extradural abscess at the petrous apex is difficult to diagnose preoperatively and has been reported in many patients with Gradenigos syndrome, it must be kept in mind in the diagnosis and the treatment of Gradenigos syndrome. Twelve cases of Gradenigos syndrome reported in Japan from 1960 to 1992 were reviewed. Acute otitis media was the cause in five, all children. In three of them abducens paralysis appeared within one week after onset of the acute otitis media. Mortality of Gradenigos syndrome is still 10%, similar to that of brain abscess associated with otitis media.

Olfactory Neuroblastoma; A Case Report.

A 49-year-old female consulted our clinic with a complaint of righ trecurrent epistaxis on December 2, 1989. A tumor was found in the right nasal cavity. Radiographic study failed to disclose the extent of the tumor, because of associated paranasal sinusitis. MRI (magnetic resonance imaging) studies suggested that the tumor was limited to the right nasal cavity. Right lateral rhinotomy was performed and the tumor was totally removed on December 27, 1989. The tumor was confirmed to be neurogenic by the findings of intracytoplasmic neurosecretory granules and neuritic processes in the tumor cells examined by electron microscopy. It was diagnosed as olfactory neuroblastoma because of its location and the normal value of urine VMA (vanillyl mandelic acid). There was no evidencel of recurrence during 18 months of follow up. The authors confirmed the usefulness of MRI in the evaluation of the extent of the tumor and the necessity of electron microscopy to diagnose olfactory neuroblastoma.

Diagnosis and surgical tretment of pharyngeal dysphagia.

We introduce here our diagnostic approaches for pharyngeal dysphagia and briefly discuss the results of surgical treatments. In dysphagia, we routinely use fluorography, manometry, electromyography and endoscopy. Fluorography in conjunction with manometry particularly provides valuable information for understanding the function of pharyngeal swallowing.Fluorography is the most important diagnostic means of studying the function of swallowing. We utilize the double contrast pharyngogram using Computed Radiography as the screening method for detecting clinical and subclinical dysphagia, since barium coating or remaining on the pharyngeal mucosa is always observed in patients with organic or functional dysphagia. Moreover, we devised a new system of pharyngo-esophagography using a video tape recorder, digital fluorography and a multiformat camera, because a contrast medium rapidly passes through the pharyngeal phase of swallowing. The video signal from the fluoroscopic unit is fed into the video tape recorder, and recorded images are transferred through the digital fluorography to the multiformat camera. Sequential images of barium swallowing in one deglutition are copied on sheet film at the rate of 30 frames per second. By this method, qualitative and quantitative assessments of pharyngeal swallowing can be carried out easily.Manometric study indicates the constricting power of pharyngeal muscles for propulsion of a bolus into the esophagus and timing of relaxation of the esophageal orifice during swallowing. The relaxation of the esophageal orifice cannot be detected by fluorography. Only a manometric approach indicates the timing, duration and degree of relaxation.We also describe our experience with surgical treatment of 19 patients with pharyngeal dysphagia caused by cerebro-vascular accidents, degenerative diseases of the neuromuscular system and myositis, and we discuss briefly the use of cricopharyngeal myotomy, section of the infrahyoidal muscles and a laryngeal elevation technique in these diseases.Finally, we emphasize the importance of multidimensional diagnostic approaches to pharyngeal dysphagia, on the basis of which the most suitable method of treatment can be selected.

Reconstruction of the mesopharynx with a lateral tongue flap in a patient with tonsillar cancer.

Using a lateral tongue flap, we reconstructed the mesopharynx after excising a tonsillar cancer in a 54-year-old male patient. Speech and deglutition were normal post-operatively. A tongue flap has the advantages of rich vascularity, good movability, excellent elasticity. Moreover, excision of the tumor and reconstruction of mesopharynx can be done in one stage in the same operative field. We emphasize that a tongue flap is one of the useful reconstructive materials in the mesopharyngeal area, especially for conservation of speech and deglutition.