Yusuke Kiyokawa

Nystagmus at the Onset of Vertiginous Attack in Ménière's Disease.

OBJECTIVE To clarify the direction and characteristics of nystagmus at the onset of a vertiginous attack in Ménières disease. PATIENTS Two patients with Ménières disease, whose nystagmus at the onset of a vertiginous attack was recorded using electronystagmography. INTERVENTIONS Diagnostic. MAIN OUTCOME MEASURES Electronystagmographic recordings of nystagmus. RESULTS In both patients, nystagmus was directed toward the affected side over the entire course of the vertiginous attack. One patient experienced a severe sensation of vertigo and exhibited strong nystagmus from the onset of the attack. The other patient reported a mild sensation of vertigo, which was accompanied by intermittent nystagmus. CONCLUSIONS Vertiginous attacks in Ménières disease are accompanied by irritative nystagmus. The intensity and characteristics (e.g., continuous or intermittent expression) of the nystagmus may be associated with pathophysiological severity.

Observation of the Pharynx to the Cervical Esophagus Using Trans-nasal Endoscopy with Image-enhanced Endoscopy for Early Detection of Head and Neck Cancers

Introduction: We started endoscopic treatment for superficial pharyngeal cancer in 1996, and thus far, 97 lesions of 77 cases of superficial head and neck cancer have been detected using trans-oral endoscopy. However, some areas are difficult to observe with trans-oral endoscopy because of the gag reflex. We have therefore applied transnasal endoscopy for observing of the pharynx to the cervical esophagus. Methods: To avoid overlooking cancers located at the floor of the mouth, soft palate and uvula, we first observe the oral cavity. After administering local anesthesia to the nose without sedation, the endoscope is inserted through the nose. When the tip of the endoscope reaches caudal to the uvula, the patient opens his or her mouth wide, sticks the tongue forward as far as possible and makes a makes a vocalization like “ayyy”. The endoscopist then makes the endoscope take a U-turn and observes the oropharynx, particularly radix linguae. To examine the hypopharynx and the orifice of the esophagus, the patient is asked to blow hard and puff their cheeks while the mouth remains closed. This approach provides a much better view of the orifice of the esophagus than is possible with trans-oral endoscopy with deep sedation. Results: In this study, we detected 22 superficial cancers of the oral cavity. Previous efforts to detect such cancers using trans-oral endoscopy have failed. In addition, we were never able to detect early cancers located at base of tongue in the past, but since implementing the intra-oropharyngeal U-turn method, we have detected more than 10 cases. We were also never able to detect early cancers located at the pharyngoesophageal junction in the past, but since implementing the modified Valsalva maneuver, we have detected more than 20 cases. Between 2008 and 2016, a total of 164 cases of 227 lesions of superficial head and neck cancer were detected by trans-nasal endoscopy, which is more than twice as many as were detected with conventional screening. Mucosal redness, white deposits or loss of a normal vascular pattern and proliferation of vascular pattern such as small dots or salmon roe with a close-up view of it are important characteristics to diagnose superficial pharyngeal cancer. Moreover, a brownish area using image-enhanced endoscopy is useful for early diagnosis. With adequate extension of the pharyngeal mucosa using the Valsalva maneuver, observing the protruded areas should prove useful for diagnosing the depth of invasion. Conclusions: Observing the pharynx to the cervical esophagus using trans-nasal endoscopy with imageenhanced endoscopy is useful for early detection of head and neck cancers.

Case of Superficial Cancer Located at the Pharyngoesophageal Junction Which Was Dissected by Endoscopic Laryngopharyngeal Surgery Combined with Endoscopic Submucosal Dissection

Aims. In order to determine the indications of transoral surgery for a tumor located at the pharyngoesophageal junction, the trumpet maneuver with transnasal endoscopy was used. Its efficacy is reported here. Material and Methods. An 88-year-old woman complaining of dysphagia, diagnosed with cervical esophageal cancer, and hoping to preserve her voice and swallowing function was admitted to our hospital. Conventional endoscopy showed that the tumor had invaded the hypopharynx. When inspecting the hypopharynx and the orifice of the esophagus, we asked the patient to blow hard and puff her cheeks with her mouth closed (trumpet maneuver). After the trumpet maneuver, the pharyngeal mucosa was stretched out. The pedicle of the tumor arose from the left-anterior wall of the pharyngoesophageal junction, so we decided to perform endoscopic resection. Result. Under general anesthesia, the curved laryngoscope made it possible to view the whole hypopharynx, including the apex of the piriform sinus and the orifice of the esophagus. The cervical esophageal cancer was pulled up to the hypopharynx. Under collaboration between a head and neck surgeon and an endoscopist, the tumor was resected en bloc by endoscopic laryngopharyngeal surgery combined with endoscopic submucosal dissection. Conclusion. Transnasal endoscopy using the trumpet maneuver is useful for a precise diagnosis of the pharyngoesophageal junction. Close collaboration between head and neck surgeons and endoscopists can provide good results in treating tumors of the pharyngoesophageal junction.