加藤 久幸

甲状腺腫瘍の標準治療は外科的切除であり，前頸部皮膚に5～10 cmの襟状切開を置くのが一般的である。甲状腺腫瘍は女性に多く若年者にも発症することもあり，整容面へ配慮した内視鏡補助下頸部手術（VANS）が施行されているが，外切開とは異なる視野による解剖的把握が困難なことや，視野や操作スペースが狭く制限されることから熟練を要する手術である。韓国を中心とした海外ではさまざまなアプローチ法によるダヴィンチサージカルシステムを用いたロボット支援下頸部（甲状腺）手術が報告されている。当施設ではカダバートレーニングでの検証を経て2022年3月よりダヴィンチXiを使用した経腋窩的ロボット支援下甲状腺手術（TART）を開始した。さらに新機種であるダヴィンチSpも導入しており，現在までに8例のTARTを自由診療にて施行した。TARTはVANSと比較して手術時間，出血量，術後合併症，入院期間に差はなく，整容性に優れ高い患者満足度が得られた。本稿ではTARTの導入と初期経験についてご紹介し，その現状と将来展望について概説する。

In this study, we report a case of tracheotomy using the ex utero intrapartum treatment (EXIT) procedure in a fetus that was pointed out as having bilateral giant cervical cysts at prenatal diagnosis and whose postnatal airway occlusion was predicted. The subject was a female aged 35. She was diagnosed with polyhydramnios at 28 weeks of pregnancy. The fetus was found to have a giant cervical cyst before she was referred to the department of obstetrics and gynecology of our hospital. On the second day of 37 weeks of pregnancy, oral tracheal intubation was attempted on the fetus using the EXIT procedure after the caesarean operation, but intubation was difficult resulting in a tracheotomy. The oxygenation of the fetus during the operation was maintained well without any postoperative complication. Postnatal fetal airway occlusion is a critical incident which may lead to the death of a fetus. It was assumed, however, that the airway management under the same procedure was completed by the preoperative detailed simulation with the staff of the departments of anesthesiology, obstetrics and gynecology and pediatrics as well as the operating room personnel.

There are many methods and types of equipment for measuring the nasal airway, but there is no consensus regarding the results of various clinical studies on nasal obstruction. In this review, we discuss the two major methods of objectively assessing the nasal airway: rhinomanometry and acoustic rhinometry. The Japanese standard of rhinomanometry in Japanese adults and children was established by the Japanese Standardization Committee on Rhinomanometry in 2001 and 2018, respectively. However, the International Standardization Committee has proposed different standards because of differences in race, equipment, and social health insurance systems. The standardization of acoustic rhinometry in Japanese adults is making progress in several Japanese institutes, but the international standardization of acoustic rhinometry has not yet begun. Rhinomanometry is the physiological expression of nasal airway breathing, whereas acoustic rhinometry is the anatomic expression. In this review, we introduce the history and methods of the objective assessment of nasal patency and the physiological and pathological issues regarding nasal obstruction.

BACKGROUND: Cervical esophageal cancer (CEC) carries a poor prognosis; however, due to its low incidence, optimal treatment for CEC remains to be established. The purpose of this study was to clarify the current status of treatment of CEC in Japan and obtain evidence for establishing the appropriate treatment method. PATIENTS AND METHODS: We asked specialist training facilities accredited by the Japanese Broncho-Esophageal Society to register data on CEC cases that received curative treatment from January 2009 to December 2014, and conducted a retrospective review of the clinical data of 302 cases registered from 27 facilities. RESULTS: In regard to the initial therapy, of the 302 patients, 33 had undergone endoscopic resection, 41 had undergone surgery, 67 had received induction chemotherapy (IC), and 143 had received chemoradiotherapy (CRT). There were no significant differences in the 5-year overall survival rates among the patient groups that had received surgery, IC or CRT as the initial treatment; advanced stage and recurrent nerve invasion were identified as independent poor prognostic factors. Among the patients who had received IC or CRT as laryngeal-preserving surgery was not indicated at the time of the initial diagnosis, the functional laryngeal preservation rate at the end of the observation period was 34.8%. CONCLUSION: Even in patients with advanced CEC, there is the possibility of preserving the larynx by adopting IC or CRT. However, if the laryngeal function cannot be preserved, there is a risk of complications from aspiration pneumonia, so that the choice of treatment should be made carefully.

Many patients with allergic rhinitis have accompanying laryngeal symptoms such as persistent cough and/or globus. Chronic laryngeal allergy is suspected to be an important cause of these laryngeal symptoms. We have been working toward establishing the concept of a new pathological condition termed "laryngeal allergy" since 1988. In Japan, the first diagnostic criteria for laryngeal allergy were established in 1995. However, these early criteria were inadequate because there was inadequate distinction between laryngeal allergy and other causes of persistent cough and globus. Therefore, more advanced criteria were reconstructed from a completely different viewpoint in 2005 to correctly distinguish laryngeal allergy from other similar diseases. The criteria established in 2005 were modified slightly in 2011 to improve the diagnostic accuracy based on the results of fundamental and clinical investigations. The Japanese Respiratory Society (JRS) included chronic laryngeal allergy in the diagnostic flowchart of the JRS guidelines for the management of cough and sputum in 2019, and chronic laryngeal allergy has recently gained wider recognition in Japan. The accurate diagnosis of conditions resembling laryngeal allergy is important in controlling cough and/or globus and preventing the unnecessary use of medical resources. Therefore, further investigations are warranted to better understand laryngeal allergy and similar diseases.

As the laryngopharynx is closely related to swallowing, speech, and phonation, it is necessary to consider not only disease control but also a minimally invasive approach for the treatment of laryngopharyngeal cancer. Transoral surgery has been reported to be a minimally invasive method for treating these diseases. Transoral videolaryngoscopic surgery (TOVS) and endoscopic laryngo-pharyngeal surgery (ELPS) have been developed in Japan and recently emerged as treatments for patients with early stage pharyngeal and laryngeal cancers. However, securing an appropriate field of view and a narrow operating space during TOVS or ELPS are critical issues to be resolved for these surgeries. The clinical significance and safety of transoral robotic surgery (TORS) using the da Vinci Surgical System have been widely reported to provide surgeons with increased visualization and magnification, resulting in precise surgical margins and rapid functional recovery. In this context, a multi-institutional clinical study was conducted to evaluate the treatment outcomes of TORS for the treatment of laryngopharyngeal cancer in Japan, and the da Vinci Surgical System for oral robot-assisted surgery for these diseases was approved by the Pharmaceutical Affairs Agency in August 2018. This review provides an overview of the therapeutic effects of TOVS, ELPS, and TORS, with a particular focus on these therapeutic results in Japan.

Severe bronchial asthma is a challenging disorder to treat and can impair quality of life (QOL) under conventional therapeutic modalities. We report the case of a 52-year-old woman with severe asthma associated with eosinophilic chronic rhinosinusitis (ECRS) and eosinophilic otitis media (EOM). Although the patient was treated with a full dose of inhaled corticosteroid, leukotriene receptor antagonist (LTRA), theophylline, burst use of oral corticosteroids (OCS), her asthmatic condition aggravated, disrupting her daily life. ECRS and EOM symptoms were also getting worse despite treatment with topical application of corticosteroids to the nose and ears, LTRA, and occasional use of OCS. In addition to asthmatic symptom, the patient always suffered from intractable nasal obstruction and hearing disturbance, which contributed to the heavily impaired QOL. However, the administration of benralizumab showed rapid and remarkable improvement not only in her asthmatic conditions but also in the symptoms of ECRS and EOM within a month. These results suggest that the use of benralizumab for the treatment of severe asthma with intractable ECRS and EOM should be considered when the patient's QOL is severely deteriorated.

BACKGROUND: Although the American Joint Committee on Cancer TNM classification has been amended to include human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) as an independent entity, to the authors' knowledge the optimized de-escalating treatment modality has not been established to date. METHODS: The authors conducted a retrospective, nationwide, observational study in patients with HPV-related OPSCC who were treated from 2011 to 2014 in Japan to determine the best treatment modality. RESULTS: A total of 688 patients who were newly diagnosed with HPV-related OPSCC who were treated with curative intent at 35 institutions and had coherent clinical information and follow-up data available were included in the current study. In patients with T1-T2N0 disease (79 patients), both the 3-year recurrence-free survival and overall survival (OS) rates were 100% in the group treated with radiotherapy (RT) as well as the group receiving concurrent chemoradiotherapy (CCRT). The 3-year OS rates were 94.4% (for patients with T1N0 disease) and 92.9% (for patients with T2N0 disease) among the patients treated with upfront surgery. In patients with stage I to stage II HPV-related OPSCC, the 5-year recurrence-free survival and OS rates were 91.4% and 92%, respectively, in the patients treated with CCRT with relatively high-dose cisplatin (≥160 mg/m2 ; 114 patients) and 74.3% and 69.5%, respectively, in the patients treated with low-dose cisplatin (<160 mg/m2 ; 17 patients). CONCLUSIONS: Despite it being a retrospective observational trial with a lack of information regarding toxicity and morbidity, the results of the current study demonstrated that patients with T1-T2N0 HPV-related OPSCC could be treated with RT alone because of the equivalent outcomes of RT and CCRT, and patients with stage I to stage II HPV-related OPSCC other than those with T1-T2N0 disease could be treated with CCRT with cisplatin at a dose of ≥160 mg/m2 .

Background: Meningiomas often invade venous sinuses, but intravenous sinus meningiomas remain within the intracranial cavity. This case report describes an extremely rare case of tentorial meningioma with venous sinus invasion, extending intraluminally into the lower part of the internal jugular vein in a 59-year-old man.Case presentation: The patient's initial surgery involved the supratentorial component of a right tentorial meningioma, which invaded the right transverse and sigmoid sinuses. The supratentorial component of the tumour did not enlarge during the 2-month waiting period for the first surgery. The patient received postoperative radiation therapy for the residual tumour in the intravenous sinus. Despite radiation, the residual tumour developed caudally and ultimately extended into the right internal jugular vein. The average regrowth speed of the extracranial mass was 3.6 mm/month. The patient underwent surgery for the recurrent tumour located in the transverse sinus, sigmoid sinus, jugular bulb, and internal jugular vein, 46 months after the initial surgery. The pathological features of both surgeries were the same; WHO grade I meningothelial meningioma.Conclusions: To the best of our knowledge, there have been few case reports of benign meningioma with intraluminal extension into the internal jugular vein, and there have been no reports of long-term observation of such cases. Detailed observation of the present case suggests that the difference in growth speed between the intracranial and venous cavity depends on the surrounding environment.