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We report a case of Kawasaki disease mimicking a retropharyngeal abscess. A boy aged 7 years and 11 months was hospitalized after 4 days with a high fever and cervical lymphadenopathy. Contrast-enhanced head and neck computed tomography (CT) showed a low-density lesion in the posterior pharyngeal space. Having all 6 clinical criteria for Kawasaki disease on hospital day 2, the boy was treated with γ-globulin, ibuprofen, and antibiotics, which gradually alleviated all clinical signs. An abscess-like retropharyngeal lesion is considered a manifestation of Kawasaki disease. Cervical lymphadenopathy is the presenting symptom in only 12% of subjects with Kawasaki disease, and may significantly delay diagnosis. It is therefore important when examining a child with a retropharyngeal abscess to consider the possibility of Kawasaki disease.

Head and neck squamous cell carcinoma (HNSCC) is globally the seventh most common cancer. Its 40–50% 5-year survival rate has not improved significantly in the last decade despite surgical, radiotherapy and chemotherapy progress. Significantly increased knowledge of biomarkers and molecular biology of HNSCC has shown that smoking and alcohol consumption cause HNSCC and that the human papilloma virus (HPV) is related to HNSCC oncogenesis. Tumor/node/metastasis (TNM) staging is essential to determining treatment and prognosis. Even early-stage subjects may have recurrence and/or distant metastasis. New biomarkers should provide new categories and staging determing prognosis preoperatively by routine tumor biopsy that, in turn, will improve HNSCC management. Here we review molecular biology of HNSCC and discuss potential analysis and treatment.

Localized laryngotracheal amyloidosis is rare, and therapeutic strategy yet to be determined. We report a case of localized laryngotracheal amyloidosis as an intraluminal tracheal mass compromising respiration. A 53-year-old woman was seen for severe dyspnea. Flexible laryngoscopy indicated subglottic stenosis, with computed tomography and magnetic resonance imaging showing a large mass lesion in the tracheal membrane. After tracheotomy, laryngotracheofissure was done for biopsy and to reduce the mass at the trachea and subglottic region, preserving as much mucosa as possible. Postoperative pathology was amyloidosis. Due to the limited effect of surgical reduction, another laryngotracheal fissure was done to completely remove the tracheal mass. The raw postresection surface was covered by atelocollagen sheet, with posterior cricoid split added to enlarge the subglottic area. The Postoperative airway was sufficient and the tracheostoma closed. No recurrence has been found 6 months after final surgery. Complete resection using laryngotracheal fissure and simultaneous laryngotracheal reconstruction with atelocollagen sheet is thus effective in treating of laryngotrahceal amyloidosis and resolving airway stenosis.

Metastasis in the thyroid gland (MT) is clinically rare, although it is increasing in number. We report three cases of MT. All cases showed a rapidly-growing mass in the neck, and were diagnosed by fine-needle aspiration biopsy. The first case was a 63-year-old man who had been treated for hepatocellular carcinoma (HCC) with chemotherapy and interferon for one year. MT was treated by thyroidectomy. He died due to primary recurrence 2 years later, but had remained free of recurrence in the neck. The second case was a 48-year-old woman, who complained of dysphagia and dyspnea. One year earlier, she had received postoperative chemotherapy for breast cancer. She underwent total thyroidectmy and died six months later due to generalized metastasis from breast cancer. There was no local recurrence in the neck. The third case was a 60-year-old woman, who had been diagnosed colon cancer three years earlier, and had been treated by a surgical resection and chemotherapy. She had also been treated for lung metastasis. MT was found after detection of brain metastasis. She underwent thyroidectomy. After the procedure, she was transferred to another hospital for additional chemotherapy and was lost to follow-up.

We report a rare case of giant cell tumor of bone arising in the 1st thoracic vertebra, which was successfully resected by a lower cervical approach. The patient was a 16-year-old female who presented with a cervical mass and dyspnea. Imaging study revealed a mediastinal mass arising in the 1st thoracic vertebra, extending upward into the lower neck. After repeated open biopsies, a diagnosis of giant cell tumor of bone was made. Curative surgery was performed by orthopedic and head and neck surgeons. Surgical exposure of the tumor was performed mainly by head and neck surgeons using a lower surgical approach without a median sternotomy. The postoperative course was uneventful and the patient is doing well without recurrence.

In 289 benign thyroid tumor operations performed at our hospital between 1988 and 1999, we treated 8 patients with mediastinal goiter, 4 of which were adenomas and 4 were adenomatous golters.It was possible to remove the goiter entirely via acervical approach in all 8 patients and even goiters extending to the aortic arch were safely removed without requiring sternotomy. There were no complications such as recurrent nerve palsy or postoperative hemorrage in those patients.The surgical approach, operative technique and results of therapy are discussed and transcervical approach for resection is emphasized.

We report a patient with a ranula extending into the parapharyngeal space. A 21-year-old male visited our clinic with complaints of right submandibular swelling for three months. Several tests including MRI were performed that led to the diagnosis of the ranula. Resection of the right sublingual gland was performed, which satisfactorily treated the cyst. We think the best treatment of a ranula is to resect the sublingual gland.

A newborn male baby was referred to our clinic with upper airway obstruction caused by a huge mass in the mesopharynx. A CT scan revealed a huge tumor existing from the left parapharyngeal space to just under the skullbase. No communication with the inside of the skullbase was detected. The tumor was determined to be heterotopic brain tissue of the parapharyngeal space and was partially excised. Since the infant was asymptomatic with normal breathing and feeding, follow up is planned in the future.

The purpose of this investigation was to examine how speech intelligibility is affected by an impact noise for listeners wearing a hearing aid. In this experiment, the subjects consisted of 10 sensorineural hearing-impaired and five normal hearing listeners. Sentences mixed with a single impact noise or without noise were presented randomly to subjects wearing a hearing aid. The hearing aids used in this experiment were digital hearing aids (TD-1) which compress the signals in the time domain, and conventional analog hearing aids with peak clipping (PC) or automatic gain control (AGC). The results demonstrated that the intelligibility of sentences mixed with an impact noise decreased when the hearing-impaired subjects wore the analog hearing aid. Interestingly, the decline in intelligibility arose in the phrases not only after the impact noise, but also before the noise. On the other hand, there was none or only a slight decrease in intelligibility, regardless of the impact noise, in the normal hearing subjects and the hearing-impaired wearing TD-1. These results indicate that the compression method adopted by TD-1 is useful for patients with sensorineural hearing loss even under conditions with impact noises. We believe that incompletely suppressed impact noises mask the speech signal, and thus causes a decrease in the speech recognition of hearing-impaired subjects wearing analog hearing aids.

Three cases of laryngotracheal stenosis were treated by a staged operation called the `trough method' in our hospital. After removing the stenotic tissues in the inner space, a trough was created. A composite auricular cartilaginous graft with overlying skin was used for the closure of the trough. First, the graft was embedded beneath the skin near the trough, with the skin graft facing the inner space of the trough. About 2 weeks later, the embedded grafts were slid over the trough. Using this procedure, the trough was closed and a firm framework could be reformed. This method has an advantage for the survival of the graft, and makes framework reconstruction safely.

Speech discrimination and hearing aid performance in patients with hearing loss have been evaluated by speech audiometry where a tape or CD is utilized as a sound source. Since all sound samples in a list on the tape or CD are consecutively presented to the examinee, this conventional method provides the perception rate of the whole list. It has been difficult however, to evaluate the perception of a specific sound in the list.We developed a new method of interactive speech audiometry. Using this method, the patient's response to each sound sample can be monitored at any required sound level. All sound samples such as the 5 vowels, 13 consonant-vowel syllables, and sentences are stored in a computer as sound files. Any sound sample can be randomly selected to present to the examinee, who replies verbally. Interactive speech audiometry can provide a more accurate evaluation of speech discrimination in patients with hearing loss.

We assessed the possibility and limitations of preserving the larynx in the treatment of Supraglottic laryngeal carcinoma. Over the period from 1988 to 1997, we treated forty-one cases which included four T1, twenty T2, five T3 and twelve T4 patients. The three year preservation rates of the larynx and three year survival rates of the patients were 75% and 100% in T1 patients, 45% and 95% in T2, and 0% and 52.9% in T3 and T4 cases. Ordinary once-a-day radiotherapy was effective in T1N0 cases, but preservation of the larynx was possible in only 37.5% of T2N0 cases. Using hyperfractionated radiotherapy, the preservation rate was improved to 75%. Supraglottic hemilaryngectomy was available to three T2 cases, whose tumors were larger than 2 cm in diameter, but had not advanced downward over the aryepiglottic fold and had no lymph node metastasis. Five advanced cases of T2 with invasion to the glottis or lymph node metastasis needed total laryngectomy. As for T3, T4 cases, although total laryngectomy and bilateral neck dissection were performed in operable cases, the three year survival rate was poor. These observations suggest that it may be difficult to preserve the larynx in T3, T4 cases.

The pectoralis major myocutaneous flap (PMMC flap) is extremely popular in head and neck reconstruction. This flap has many advantages over local cutaneous flaps, free flaps, and fasciocutaneous flaps. At our institute, this flap is the first choice among the various reconstructive methods used for the correction of tongue defects after primary tumor resection. We experienced synchronized contraction of the PMMC flap with adduction of the ipsilateral arm over a 1 year postoperative period. After severing of the nerves innervating the flap, this unusual contraction disappeared.

Histological differential diagnosis of malignant head and neck tumors in childhood, including malignant lymphoma, neuroblastoma and rhabdomyosarcoma, is occasionally difficult, since these tumors are classified as small-round-cell tumors. Recently we diagnosed and treated four children with rhabdomyosarcoma, originating in the head and neck. In three patients, immunohistological diagnosis using monoclonal antibodies against cytoskeletal proteins led to the accurate diagnosis of rhabdomyosarcoma. In the remaining one patient, the myogenic regulatory gene (MyoD1) RNA expression in the tumor tissue facilitated a final diagnosis of immature rhabdomyosarcoma.The usefulness of immunohistological and molecular diagnosis of rhabdomyosarcoma is emphasized.

Intracapsular enucleation is thought to be a suitable method for preserving post-operative function of the original nerve following treatment for cervical neurilemmomas. In previous studies, however, post-operative palsy occurred in most cases and there have been seen several cases in which nerve funtions did not recover. In the present study, we performed a modified method of Intracapsular enucleation for two cervical neurilemmomas, the first case involved the facial nerve, the second the hypoglossal nerve. In these cases, post-operative palsy has not been observed since immediately after surgery. Important points in this procedure include (1) making the incision line at a point on the capsule where few nerve fibers exist, (2)ablating the capsule from the tumor as gently as possible, (3) monitoring nerve function using a nerve stimulator throughout the procedure.

Compound action potentials (CAPs) of human auditory nerves evoked by the short syllables /a/ and /ka/ were recorded with extratympanic electrocochleography in ten volunteers. Periodic CAPs at the same frequency as the fundamental frequency of the voice were observed in the vowel /a/ and the voiced segment of ka . At the beginning of both syllables a prominent CAP was observed, although no CAP was evoked at the voice onset of /ka/. The voiced segment of /ka/ showed different discharge patterns of CAPs from the vowel /a/. These results suggest that some frequency information of vowels can be transformed to temporal information in the human cochlea. Temporal patterns of CAPs are believed to contribute to consonant recognition.

Event-related magnetic fields (ERFs) were recorded in seven subjects when they were presented with a rectangle and Japanese Kanji characters, followed by vocalizations. The ERF averages for the Kanji characters were different from those for the rectangle at latencies of about 100ms over the occipital lobe and 150-500ms over the temporo-parieto-occipital region. This observation suggests that the first stage of visual word processing might arise in the occipital lobe.In some cases, difference between the ERFs for the Kanji characters and those for the rectangle were also seen in the frontal lobe at latencies greater than 250ms. This observation suggests that frontal lobe activity may be also involved in visual word processing.Three equivalent current dipoles were estimated on the bilateral precentral gyrus (motor area) and the posterior part of the superior frontal gyros (supplementary motor area) at a latency of about 500ms during vocalization.In some cases, early responses at latencies of less than 150ms were obtained in not only the occipital lobe but also the frontal and temporal lobes. This suggests that parallel processing might occur during visual word processing.

Temporal resolution is an important factor in auditory processing, especially in speech recognition. For evaluation in humans, many experiments such as gap detection test (gap test), have been conducted mostly with psychoacoustic methods. To objectify temporal resolution, we designed an electrophysiological gap test using auditory evoked brainstem responses (ABRs). ABRs were elicited by a probe tone (4 kHz, 75 dBnHL, 2 msec duration, tone burst) with a preceding masker tone (4 kHz, 75 dBnHL, 50 msec duration, tone burst) in 20 young subjects with normal hearing. As two tone intervals (gaps) were shortened from 10 msec by 2 msec, the amplitudes of wave V were decreased and became undetectable. The thresholds for wave V detection regarded as gap detection thresholds ranged from 2 to 6 msec with an average of 4.8 msec, which is similar to the results of the psychoacoustic gap test introduced by Shailer and Moore in 1989.This test is useful in the objective evaluation of temporal resolution in humans.

To determine the role of temporal information in speech perception, we created synthesized sound with temporal information alone and without such information as formant. To create such a sound, we plot the zero-crossing point in the original sound wave and place clicks on each point. So this sound consists of clicks. This stimulus sound contains only the timing information of stimulation and no significant information on the formant on the sonagram. Various types of this stimulus sound were created from the original sounds of Japanese vowels, VCV syllables, sentences with meaning and without meaning, song with background music and jazz instrumental music. We performed hearing experiments using this sound in twelve normal volunteers. The results showed that the perception of simple sounds (vowel, VCV syllable) were near the chance level. The perception of meaningless Japanese sentences were poor. Japanese sentences with meaning were well perceived. The perception of instrumental music was quite poor. These results suggested that the temporal information plays an important role in speech perception.

Although many types of digital hearing aids have been developed, speech recognition with such hearing aids has not been greatly improved in patients with sensorineural hearing loss. We examined speech recognition with a different approach by converting original speech waves to amplitudedichotomized rectangular waves (zero-crossing). Characteristics of zero-crossing are an increase of temporal information of speech and a decrease of frequency information. Japanese sentences converted by zero-crossing were prepared for examination. We tested speech recognition with sentences converted by zero-crossing and with unconverted sentences in 19 patients with sensorineural hearing loss and 14 volunteers with normal hearing.The results showed that zero-crossing improved the speech recognition of the patients with the phenomenon of loudness recruitment. In the 11 of 14 patients with recruitment phenomenon (78.6%), the intelligibility of sentences converted by zero-crossing was better than that of unconverted sentences, while for the other patients zero-crossing was not effective. These results suggest that temporal information is also important for speech recognition. The incorporation of zero-crossing in hearing aids is thought to be effective in speech recognition by patients with sensorineural hearing loss.

Compound action potentials (CAPS), synchronized potentials by firings of many fibers in the auditory nerve, are thought to represent temporal information related to sound coding in the cochlea. In the present study, CAPs in nine guinea-pig cochleae evoked by speech sounds were examined by electrocochleography. CAPS were evoked at (1) onset of voiceless stop consonants [p], [k], [t], and voiced stops [b] in every cases, (2) onsets of voiced stops [d], [g] in some cases and (3) onset of semi vowels [w] in some cases. CAPs were not observed at other consonants or semi vowel [y], and seldom observed at the onset of vowels in consonant-vowel syllables.It is concluded that some inf ormations which are important for speech recognition such as the onset of stop consonants is coded as temporal information, synchronized firing of auditory nerve fibers, in the cochlea.

In general, the primary therapy for mutational voice disorder is voice therapy since the disorder is believed to be mainly functional. However, we sometimes see organic changes such as slight vocal cord atrophy in some patients with mutational voice disorder who have mainly voice breaks as well as high pitch and hoarseness. We assume that asynchronous growth of the laryngeal cartilage and vocal cords might cause imbalance of tension of the vocal cords that results in atrophic appearance of vocal cord and prolonged mutational voice. When organic changes such as atrophy or tension imbalance of the vocal cords exist, voice therapy may not be effective and surgical treatment may yield better results.We performed thyroplasty type III with lateral compression in three patients with mutational voice disorder with organic change. If the imbalance of the vocal cord tension causes mutational voice disorder associated with vocal cord atrophy, thyroplasty type III conbined with lateral compression may correct both the imbalance of the vocal cord tension and the glottal gap caused by vocal cord atrophy.The effect of the operation was rapid and dramatic. In all three patients the voice pitch became much lower immediately after the procedure, and breathiness and voice breaks were reduced or disappeared. None of the patients required voice therapy after the operation. In conclusion, thyroplasty type III is quite effective for mutational voice disorder with unilateral vocal cord atrophy.

Intrathyroid thymoma is a rare tumor. A 55-year-old male visited our hospital for acute laryngitis. We noted a thyroid tumor incidentally. The tumor, located in left lobe, was resected, and the histopathological diagnosis was intrathyroid thymoma. Postoperative radiation was performed.

The incidence of thyroid papillary carcinoma (PAC) in benign thyroid disease (BTD) such as Graves' disease, follicular adenoma (FA), chronic. thyroiditis, and adenomatous goiter (AG) was determined in 38 patients with PAC among 187 with BTD whose thyroid glands were removed surgically.The incidence of PAC was 24.1% in AGs and 9.8% in FAs. The problem of preoperative diagnosis of thyroid disease with ultrasonography is that in some cases we could not recognize small PACs in thyroids disease with benign, and in other cases it was hard to distinguish PACs from benign nodules in thyroids with multiple nodules. The incidence of lymphnode metastasis was 33.3% when the preoperative diagnosis was BTD, so we must always look for PAC in patients with BTD.

There have not been many reports of ethmoid osteomas in the Japanese literature. The most commonly described symptons are facial pain and headache. We recently treated a patient with ethmoid osteoma causing epiphora by compression of the lacrimal sac.She was 60 years old and complained of left epiphora. We diagnosed ethmoid osteoma on the basis of X-ray and CT scan findings. The epiphora was completely relieved by removal of the osteoma compressing the lacrimal sac.

A 56-year-old woman visited our hospital because of nasal pain. Physical examination revealed a gray mass in the right nasal cavity. Precontrast CT scan showed a lesion with iso-density relative to the muscles, which had intermediate signal intensity on Ti-weighted MR image and high, partially low, signal intensity on T2-weighted image. The mass was totally removed by an endonasal approach, and histological examination showed interlacing bundles of tumor cells, confirmed as smooth muscle cells by immunohistochemistry and electron microscopy.

Radiation-induced cancer of the head and neck is well known, but radiation-induced sarcoma is rare. Only nine cases have been reported in the Japanese literature. We treated a patient with post irradiation sarcoma arising in the maxillary sinus. She is now 60 years old and had received radiation therapy for left maxillary carcinoma in 1952. In 1972, left maxillary sarcoma was found and she received postoperative radiation therapy again. Then right nasal carcinoma was found in 1980, and she again received postoperative radiation therapy. Then left maxillary sarcoma was found in 1992. There have been no previous reports of three consecutive radiation-induced malignancies developing in a patient.

Therapeutic results for 46 patients with distant metastases of head and neck cancers other than thyroid cancer, treated at Tenri hospital from 1975 to 1992, were evaluated. Of 57 sites of metastases studied, 30 were in the lung, 11 the liver and 11 the bone. Chemotherapy, radiotherapy and surgery were performed singly or in combination and the results for each site of metastases was analysed. For lung metastases, radiotherapy or surgery, if possible, is considered effective in improving the prognosis. The prognosis for liver metastases was quite poor, but transarterial infusion into the hapatic artery was expected to prolong the survival period. Radiotherapy for bone metastases was quite effective, while chemotherapy had little effect. Active therapy for distant metastases was expected to improve the quality of life.

We devised a new method of dynamic reconstruction which sutures the cricothyroid muscle with the paralyzed lateral cricoarytenoid muscle.Since this method achieved remobilization of paralyzed vocal cords in dogs, we applied it to seven patients with unilateral recurrent laryngeal nerve paralysis (four, postsurgical paralysis; three, idiopathic paralysis).The results were as follows: 1) in all cases, tension of the vocal cord was good and voice quality was improved, 2) in four patients, remobilization of the paralyzed vocal cord was obtained.We conclude that the clinical application of this method can serve as a new dynamic reconstruction for the treatment of unilateral recurrent laryngeal nerve paralysis.

Between 1992 and 1998, 67 patients underwent a subtotal thyroidectomy for hyperthyroidism (Basedow disease). Postoperative complications occurred in 6 patients (9.0%). In 4 patients (6.0%), postoperative bleeding occurred, which was stopped by a reoperation. Postoperative recurrent laryngeal nerve palsy occurred in 2 patients (3.0%); they recovered from the palsy within three weeks. One patient (1.5% needed vitamin) for 5 years after the operation due to hypo calcemia.We should choose a subtotal thyroidectomy as treatment for hyperthyroidism because very few patients are expected to suffer from severe complications.

In microsurgery of the larynx, it is desirable for the surgeon during operation, to listen to the voice of the patient, observe the vibration of the vocal folds and perform the operation with simple procedures.Such an operative method was devised, in which the operator can use both hands freely. Local anesthesia and a stroboscope are important elements. We named this method FIBER-OPTIC LARYNGO MICROSURGERY WITH STROBOSCOPE and describe it here.Just as in conventional surgery under local anesthesia, the patient is in the sitting position and the nasal cavity, oral cavity, pharnx, hypopharynx and larynx are anesthetized with 4% xylocaine. An assistant insert the laryngeal fiberscope connected to a strobe light through the nasal cavity, and an endolaryngeal image is displayed on a monitor screen. The patient holds his tongue with one hand, so the operator can use both hands freely. Watching the monitoring screen, the doctor can operate with instruments in both hands and finish the operation when satisfactory phonation is obtained.This operation was performed in 22 patients with vocal fold polyp or polypoid vocal fold. Acceptable phonation was obtained in all patients without suspension of the operation.The advantages of this method are; 1) it can be applied in outpatients without laborious preparation; 2) it does not involve complex procedures; 3) it allows the doctor to observe vibrations of the vocal folds; 4) magnified images of the lesion can be observed; 5) both hands can be used freely.