論文

59歳男性。糖尿病の通院中に右外頸動脈付近の腫瘤を指摘された。MRIで右茎突前隙に外頸動脈を巻き込む様に存在する、内部不均一で長径7cm大の数珠状の腫瘤を認めた。超音波では腫瘤の一部が嚢胞成分を伴っていた。耳下腺深葉多形腺腫と診断し、耳下腺深葉切除術に準じて摘出術を施行した。腫瘤は顔面神経下枝の深部に存在し、尾側は顎二腹筋腱上、頭側は顔面神経上下枝の分岐部付近まで進展していた。顔面神経は温存し、外頸動脈は腫瘤内部を貫通する様に走行していたため、結紮切断した。病理診断はAntoni B型の神経鞘腫であった。術後7日の食事開始時に右耳下腺部痛が出現し、first bite syndrome(FBS)を発症したと考えられた。神経脱落症状としてFBSとカーテン徴候を認めたが、Horner症候群はみられなかった。術後半年の現在、神経脱落症状としてFBSのみが残存しているが、QOLの低下はなく、無治療で経過観察している。

It is said that Horner syndrome and first bite syndrome (FBS) could occur after cutting off the sympathetic trunk during surgery for parapharyngeal space tumors. We encountered a patient who developed FBS without Horner syndrome after removal of a parapharyngeal space tumor, which was eventually diagnosed as a sympathetic schwannoma. A 59-year-old male patient was detected by ultrasonography as having a tumor near the external carotid artery. MRI showed a moniliform-shaped parapharyngeal space tumor surrounding the external carotid artery, and fine-needle aspiration cytology revealed some cells with spindle-shaped nuclei. There was no evidence of any neurological deficit. We performed resection of the the parapharyngeal tumor, which was not apparently connected to any nerve. The external carotid artery was ligated, because it was surrounded by the tumor. Seven days after surgery, he developed preauricular pain at the beginning of a meal and was assumed to have developed FBS. The curtain sign was also positive, but there was no evidence of Horner syndrome. Histopathological examination of the tumor revealed the diagnosis of schwannoma. It is reported that FBS occurs when sympathetic innervation from the superior cervical ganglion to the parotid gland is lost and the receptor sensitivity on the parotid gland increases. Since the sympathetic nerve branch to the parotid gland runs around the external carotid artery, it is reported that FBS more commonly appears in cases where the external carotid artery is sacrificed. In our case, the tumor surrounding the external carotid artery and the fact that the patient developed FBS without Horner syndrome after surgery suggest that the tumor arose from the sympathetic branch to the parotid gland. The case also lends support to the hypothesis proposed to explain the mechanism of development of FBS.

Purpose: To determine pre- and post-treatment factors that are useful for predicting the prognosis of hearing improvement in idiopathic sudden sensorineural hearing loss (ISSHL). Methods: This retrospective study included 332 patients with ISSHL. Patients received intravenous steroid treatment (prednisolone sodium succinate; 120 mg/day followed by dose tapering). Complete recovery of hearing levels was defined as a final pure-tone audiometry of ≤ 20 dB HL or the same level as the contralateral ear. Patients’ age; sex; side of hearing loss; initial hearing level; days from onset to treatment; presence of vertigo, diabetes, and hypertension; and hearing improvement on days 3–4 and 6–7 after treatment initiation were analyzed as potential prognostic factors. Results: Overall, 109 patients (32%) had complete recovery. Results of the multivariate logistic regression model identified age (odds ratio [OR] = 0.974), initial hearing level (OR = 0.949), vertigo (OR = 0.409), and hearing improvement on days 6–7 after treatment initiation (OR = 1.11) as significant independent predictors of complete recovery. Age ≥ 60 years, initial hearing level ≥ 72.5 dB HL, and vertigo contributed to poor prognosis. Patients without these three factors and a hearing improvement of ≥ 10 dB HL on days 6–7 post-treatment had a complete recovery rate of 80%. Only 1.5% of the patients with 2–3 of these factors and a hearing improvement of < 10 dB HL on days 6–7 after treatment initiation achieved complete recovery. Conclusion: Age, initial hearing level, vertigo, and hearing improvement on days 6–7 after treatment initiation were independent predictors of hearing recovery in ISSHL.

Background: Inflammatory pseudotumors (IPTs) are rare, idiopathic, and inflammatory lesions that are histopathologically benign. Here, we present three cases of labyrinthine destruction caused by an IPT. Methods: The first patient was a 74-year-old male with a mass lesion extending from the inner ear to the external ear canal. The second patient was a 62-year-old female with a foliated polycystic lesion in the petrous bone on the dorsal side of the left internal auditory canal. The third patient was a 68-year-old female with a mass extending from the inner ear to the middle ear, destroying the semicircular canal and cochlea. Results: In two cases, we performed surgical resection successfully with no recurrence. In the other case, the lesion showed shrinkage after chemotherapy for colorectal cancer incidentally found during the examination process. Conclusion: Surgical technique and indication for IPT should be based on the location and function of the lesion. In addition, there is room to consider pharmacotherapy as a treatment option for IPT of the temporal bone. Level of Evidence: 4.

Among cervical traumas, tracheal injuries can be particularly life-threatening because of the risk of airway disruption and require immediate diagnosis and proper management Delays in diagnosis can cause a worsening of subcutaneous emphysema and dyspnea during the acute stage, resulting in cicatricial airway stenosis during later stages. However, the absence of specific symptoms and/or physical signs often makes a prompt diagnosis difficult. In this paper, we report three cases of penetrating traumatic injuries to the trachea and provide a review of the literature concerning traumatic tracheal injuries. All three patients in our case series experienced a penetrating cervical trauma consisting of stab wounds inflicted with a knife, including self-mutilation in one patient and attacks by others in two patients. All three patients underwent emergency surgery during which the injured tracheas were successfully repaired; the recoveries of all three patients were uneventful. Since definitive diagnosis by direct palpation of the wound was possible in only one patient, indirect clinical findings seem to be important for the diagnosis of tracheal injury. Subcutaneous emphysema appeared in all three patients, as it has previously been reported to develop frequently and nonspecifically. Air leakage was found in two patients, suggesting a relatively high specificity of this sign for airway injuries. Computed tomography implied tracheal injuries in two patients, but we could not determine the exact anatomical site and extent of the injuries. Although the injuries were located on the thoracic trachea in the two patients harmed by others, these lacerations were successfully closed using a transcervical approach through the primary cervical skin wounds. Based on our experiences and those reported previously, patients with penetrating cervical injuries who were harmed by others and/or whose skin wounds were located in the vicinity of the suprasternal notch should be suspected of having penetrating injuries to the thoracic trachea. Even if a physical examination is combined with diagnostic imaging, a definitive diagnosis of penetrating tracheal injury and the assessment of its exact location and extent can still be difficult. Therefore, in cases where a penetrating tracheal injury is suspected and if the patient's general condition permits, we recommend surgical exploration by exposing the trachea with sufficient counter-traction, followed by primary closure with appropriate sutures.

Background: Febrile neutropenia (FN) is the most serious hematologic toxicity of systemic chemotherapy. However, accurate prediction of FN development has been difficult because the risk varies largely depending on the chemotherapy regimen and various individual factors. Methods: We retrospectively analyzed diverse clinical factors including pretreatment hematological parameters to clarify the reliable predictors of FN development during chemotherapy with a docetaxel, cisplatin, and fluorouracil (TPF) regimen in patients with head and neck squamous cell carcinoma. Results: Among the 50 patients, grade ≥3 neutropenia, grade 4 neutropenia, and FN developed in 36 (72%), 21 (42%), and 12 (24%) patients, respectively. Multivariate logistic regression revealed that a pretreatment absolute monocyte count (AMC) < 370/mm3 is an independent predictor of TPF chemotherapy-induced FN (odds ratio=6.000, p=0.017). The predictive performance of the model combining AMC and absolute neutrophil count (ANC), in which the high-risk group was defined as having an AMC < 370/mm3 and/or ANC < 3500/mm3, was superior (area under the curve [AUC]=0.745) to that of the model with a cutoff for AMC alone (AUC=0.679). Conclusions: On the basis of our results, we recommend primary prophylactic use of granulocyte colony-stimulating factor and/or antibiotics selectively for patients predicted to be at high risk for TPF chemotherapy-induced FN.

The cause of idiopathic sudden sensorineural hearing loss (idiopathic SSNHL)—diagnosed after excluding other causes of hearing loss, such as SSNHL associated with vestibular schwannoma (VS)—is unknown. The presumed pathogenesis of idiopathic SSNHL includes circulatory disorders (e.g., cochlear infarction). We tested the hypothesis that patients with SSNHL who are at high stroke risk will have a lower rate of VS compared to those with low stroke risk. The rationale is that the primary cause of SSNHL in patients with high stroke risk might be a circulatory disturbance. We conducted a retrospective study in six hospitals. Our sampling of SSNHL patients included those diagnosed with idiopathic SSNHL and VS-associated SSNHL. SSNHL patients who had a head MRI were stratified by severity of hearing loss and evaluated for differences in the detection rate of VS between the high-scoring CHADS2 (CHADS2-H-), an index of stroke risk, and low-scoring CHADS2 (CHADS2-L-) groups. We identified 916 patients who met the inclusion criteria. For severe hearing loss, the CHADS2-H group had a significantly lower rate of VS than the CHADS2-L group (OR 0 [95% CI 0.00–0.612]; P = 0.007). These results indirectly support the hypothesis that a primary cause of severe idiopathic SSNHL in those at high risk of stroke might be a circulatory disorder.

Background: The spinal accessory nerve (SAN) has several anatomical variations, which may be a pitfall in neck dissection (ND). These include the trapezius muscle branch (TB), which stems from the common trunk before entering the sternocleidomastoid muscle (SCM). Aims/Objectives: To investigate the prevalence of this variation and suggest a protocol for preventing unexpected injury of the TB in ND. Materials and methods: We conducted a retrospective cohort study for 93 patients who had undergone neck dissection (117 sides) without resection of the SCM nor SAN. We recorded the division of the TB after and before penetration of the SCM by the common trunk (penetrating type TB [PTB]) and non-penetrating type TB [NPTB], respectively). Results: Among NDs, PTB and NPTB were observed in 61 (52%) and 56 (48%) sides, respectively. In the subgroup of 24 cases with bilateral ND, PTB/PTB, NPTB/NPTB, and NPTB/PTB were observed in eight (33%), nine (38%), and seven (29%) cases, respectively. The prevalence of PTB/NPTB did not differ according to age, sex, or laterality. Conclusions and significance: NPTB is a common anatomical variation. The presence or absence of a branch from the common trunk must be initially checked to avoid unexpected damage to the TB.

Purpose: Carotid artery invasion by metastatic lymph nodes in head and neck squamous cell carcinoma (HNSCC) is one of the diagnostic criteria for unresectable tumors. However, to date, the diagnostic criteria for carotid artery invasion have not been well documented. This study investigated the utility of computed tomography (CT) findings as a predictor of carotid artery invasion by metastatic lymph nodes in HNSCC. Methods: Twenty-eight patients who had metastatic lymph nodes of HNSCC attached to the carotid artery as seen on CT images before neck dissection from January 2011 to November 2017 were included. Five imaging parameters (angle of contact [AC], length of contact [LC], haziness of the carotid artery wall [HW], size of the lymph node, and involvement of the bifurcation of the carotid artery [IB]) were assessed using CT to predict carotid artery invasion. Furthermore, the utility of the combination of these five parameters was evaluated. Results: There were significant differences in AC, LC, and IB between patients with and without carotid artery invasion. There were significant differences in all combinations of the two image findings between patients with and without carotid artery invasion. In particular, the combinations of LC and HW, and LC and IB could clearly predict carotid artery invasion. Conclusion: AC, LC, and IB were useful predictors of carotid artery invasion of metastatic lymph nodes in HNSCC. This study is the first to report that IB is a useful predictor of carotid artery invasion in HNSCC.

音楽幻聴は、外部からの音刺激がないのに歌や旋律が自然に聞こえる現象であり、耳鳴患者の中にも稀に存在する。2011年1月から2018年10月までに当科を受診した耳鳴患者のうち、音楽幻聴を訴えた23例の臨床像を検討した。このうち11例に対し耳鳴について詳細に説明した上で補聴器による音響療法を行い、治療効果を検討した。音楽幻聴症例は、高齢者・女性に多く1例を除く全例で感音難聴を認めた。全例で病識が保たれており、精神神経科疾患の合併を認めなかった。治療後にTinnitus Handicap Inventoryの合計値、耳鳴の自覚的大きさ・苦痛のVisual Analogue Scaleは有意に改善した。本検討から、精神神経科疾患の合併がなく難聴が主病因の音楽幻聴に対し耳鳴の説明と補聴器による音響療法が有効な治療である可能性が示唆され、耳鼻咽喉科医が中心となり診療に携わることが望ましいと考えられた。(著者抄録)

頸部外傷の中でも、特に気管損傷は気道緊急疾患で迅速な対応を要する。また早期に診断・治療がなされなかった場合、急性期には皮下気腫の増悪や呼吸障害の出現、長期的には瘢痕性気道狭窄が生じることがある。当院で最近経験した3例の鋭的気管損傷例について報告し、その診断・治療について検討した。3例いずれも刃物による頸部刺傷に起因し、受傷機転は自傷1例、他害2例で、いずれも緊急手術にて気管損傷を確認・閉鎖し、気道の後遺障害を残さず治癒した。術前に創部触診で気管損傷を直接触知し得たのは1例のみで、診断にはそのほかの間接的臨床所見が重要と考えられた。皮下気腫は全例に認められ、非特異的ではあるが過去の報告に一致して高頻度であった。エアリークは2例に認められ、気管損傷を強く示唆する重要な所見と考えられた。CTでは気管損傷を疑う所見を2例に認めたが、損傷の部位と程度の評価は困難であった。損傷部位は他害の2例では胸部気管に位置していたが、いずれも経頸部アプローチにて閉鎖可能であった。過去の報告を踏まえると、他害例や胸骨上切痕部に皮膚切創がある場合には胸部気管損傷の可能性を考える必要がある。鋭的気管損傷においては、臨床所見および画像診断を合わせても確定診断のみならず損傷の部位や程度の評価に限界があることから、疑われる場合には、全身状態が許されれば創部の十分な展開による診断と評価および閉鎖術が勧められる。(著者抄録)