楯谷 一郎

過去4年間に手術を行った甲状腺腫瘍228例のうち,術前の穿刺吸引細胞診でクラスIII(境界病変)の診断を得ていた37例を対象に,術前所見と良悪性との関連について検討した.37例中悪性であったものは17例(46%)と約半数を占めていた.更に術前の病歴,触診,画像所見から手術除外例を予測し得ないか検討した結果,触診上軟らかく石灰化がない症例,境界明瞭で軟らかい症例では14例中13例が良性と殆どが良性であったが,濾胞癌の1例を含んでいた.悪性例が半数を占めていたこと,良性の可能性が高い例は見出せるものの濾胞癌の可能性は否定できないことより,クラスIIIであれば手術適応とするのが妥当と思われた

To preserve the laryngeal function in cases of T2 glottic carcinoma, we performed hyper-fractionated radiotherapy on 21 cases with T2 glottic carcinoma from 1992 to 1999. The total dose administered ranged from 72 to 74.4 Gy. After radiation, two cases had neck lymph nodal recurrences, but both were salvaged by radical neck dissection. Only one case had local recurrence. She died of lung metastasis. No major complications, such as laryngeal necrosis, were seen in any of the cases. Statistical processing was performed, based on the Kaplan-Meyer method, with the results being that the 5-year-survival rate was 95.2% and the 5-year-laryngeal preservation rate was 95.2%. Hyperfractionated radiotherapy was useful for preserving the larynx in cases of T2 glottic carcinoma.

We designed a new type of nonlinear digital hearing aid (TD-1) with near-instantaneous amplitude compression for sensorineural hearing-impaired people. The amplification method utilized by the TD-1 normalizes the signal waveforms within a time window bounded by two adjacent positive going zero-crossing points. The signals within this window are amplified so that the maximum amplitude reaches a preset value, thus allowing a consistent peak amplitude to be maintained. To test this, we examined the efficacy of the TD-1 device in 31 patients with sensorineural hearing loss. When tested for recognition of Japanese sentences in a quiet environment, 7 of 25 (28.0%) subjects wearing the TD-1 showed a 20% or greater increase in the maximum intelligibility score than that obtained when wearing their own linear hearing aids. In addition, 7 of 31 (22.6%) subjects showed the same increase with the TD-1 relative to that obtained when they wore HA70 or HA73 devices (Rion Co., Ltd., Tokyo, Japan), which are conventional analogue hearing aids. These results indicate that TD-1 can be effective for patients with sensorineural hearing loss.

1)新生男児.診断には病理学的所見に加え,矢状断MRIが有用であった.2)本例のように副咽頭腔から頭蓋底まで達する例では外科的切除は極めて困難であり,呼吸,哺乳の確保を目的に減量術に留めて,増大傾向がなければ経過観察を行うのが適当と考えられた

慢性甲状腺炎に伴う甲状腺腫大によって気管狭窄をきたし,呼吸困難に至った例を2例(50歳男,45歳女)経験した.2例とも手術的に甲状腺を切除することにより,気管の狭窄が解除され,呼吸困難が改善した.慢性甲状腺炎でも甲状腺腫大が強く,気管狭窄,呼吸困難をきたし,保存的治療が無効な例では,手術療法が有効であると考えられた

Background: It is believed that the number of neurons of the human cortex increases rapidly in the first postnatal year, and then decreases gradually towards adult level as their functions are revised up to 11 years of age ('synaptic revision'). It is also confirmed that regional cerebral blood flow (rCBF) at rest represents the density of the neurons and decreases in accordance with the synaptic revision in process. If synaptic revision does not occur, rCBF remains at high level. Thus, we can evaluate whether functional differentiation has occurred in the human cortex by measuring rCBF at resting state. Objective: To examine functional differentiation of the auditory association area (A2) in prelingually deaf subjects. Methods: Six postlingually and six prelingually deaf subjects who had undergone cochlear implant (CI) were involved in the current study. All prelingually deaf subjects underwent CI over 8 years old. The rCBF in A2 was examined during resting and listening to speech sounds using positron emission tomography (PET) and H2/15O intravenous injection. Twelve normal subjects' rCBFs were also measured as control. Furthermore, three prelingually deaf subjects underwent follow up PET studies in which cortical activities in A2 for listening and lipreading were examined. Results: In the examination of rCBF at rest, rCBFs of prelingually deaf subjects in A2 showed significantly higher than those of either the postlingually deaf subjects or normal subjects. During listening, rCBFs in A2 increased in postlingually deaf subjects and normal subjects, while there was no significant rCBF increase in the prelingually deaf. High rCBF level in A2 at rest observed in prelingually deaf subjects implied a lack of synaptic revision, and it was suggested that the functional differentiation for auditory processing was little in the A2 of prelingually deaf subjects. In the follow up study for three prelingually deaf subjects, activation of A2 was observed during lipreading but not during listening in two cases, who had developed the skill of lipreading while speech recognition was not improved by CI. In contrast, the other case had not used any visual clues in daily communication prior to CI, and the hearing acuity was well improved by CI. This case demonstrated an activity in A2 during listening, while lipreading induced no activation. Conclusion: It is suggested that functional differentiation of A2 should differ according to which of visual and auditory clue is chiefly used during critical periods for speech acquisition. The findings are thought to be important for us to schedule the education and treatment for prelingually deaf children. (C) 2000 Elsevier Science Ireland Ltd.

バセドウ病甲状腺亜全摘例67例について術後合併症について,術後出血4例,一過性反回神経麻痺2例,永続性低カルシウム血症1例であった

To investigate the cortical activities while listening to noise and speech in cochlear implant (CI) users, we compared cerebral blood flow in postlingually deafened CI users with that in normal hearing subjects using positron emission tomography. While noise activation in CI users did not significantly differ from that in normal subjects, hearing speech activated more cortical areas in CI users than in normal subjects. A comparison of speech activation in these two groups revealed higher activation in CI users not only in the temporal cortices but also in Broca's area and its right hemisphere homologue, the supplementary motor area and the anterior cingulate gyrus. In postlingually deafened subjects, the hearing of speech coded by CI may be accompanied by increased activation of both the temporal and frontal cortices. Copyright (C) 2000 Elsevier Science B.V.

機能性発声障害のうち,変声障害7例,痙攀性発声障害2例,及び無力性発声障害1例に対し喉頭枠組み手術を施行し良好な結果を得た.術式の選択には各喉頭所見を正確に把握することが重要と考えられた

We assessed the surgical effects of Isshiki's thyroplasty on 10 functional voice disorder patients including seven with mutational voice disorder, two with spasmodic dysphonia and one with asthénie voice disorder. Our concept is to select and combine proper surgical procedures according to the laryngeal findings of each case. We conveyed thyroplasty type I and ffl for six patients, and type H and ffl for one with mutational voice disorder. For spasmodic dysphonia, thyroplasty type IIand IK was performed in one case with atrophy of the vocal folds accompanied by contraction of false vocal folds during phonation, while type II thyroplasty was selected for the other case without vocal fold atrophy and supraglottic contraction. One asthénie voice disorder was treated with thyroplasty type n and HI. We showed the efficiency of framework surgery for functional voice disorders and discussed how to select the type of thyroplasty for each case.

We reviewed the literature related to the processing of visual and tactile language in the central nervous system as demonstrated by functional brain imaging techniques. Written word recognition activates not only the visual association areas but also the temporal region, especially in lexicsemantic processing. In lip reading and sign language recognition, the auditory association areas may play an important role in addition to the visual association areas both in the case of normal subjects and congenitally deaf subjects. In the case of congenitally blind subjects, visual association areas may play an important role in the processing of speech and Braille reading. In the case of congenitally deaf subjects, the auditory cortex may be involved in the processing of vibratile stimuli. These findings suggests the cross-modal plasticity of the brain in the processing of language. This paper also discusses problems to be resolved in the future.

A rare case of paraganglioma arising in the vagus nerve and carotid body is reported. A tumor occupying the right parapharyngeal space was revealed incidentally by computed tomography in a 46 year-old woman. The tumor was located between the common carotid artery and the internal jugular vein and was removed transcervically with vagus nerve. After the operation, Horner's symptom and hoarseness occurred and thyroplasty was performed. Six months after the operation, a right neck mass occurred and angiography showed a high vascular tumor in the widened carotid bifurcation. The tumor was resected transcervically. The patient's elder brother had also exhibited a glomus-jugular tumor and had died of intracranial invasion. This case is the first familial case and the third multiple case of vagal paraganglioma reported in Japan.

Objective: To examine the effect of a new surgical intervention, consisting of cricopharyngeal myotomy and tracheal cartilaginous implantation on the anterior wall of the esophagus, for tracheoesophageal shunt and esophageal phonation. Design: We examined the vibration of the neoglottis of tracheoesophageal shunt and esophageal speakers after total laryngectomy using a high-speed video camera (frame rate, 1000 per second). Patients: Twenty-one alaryngeal patients were involved: 13 who had undergone the present procedure and 8 who had not. Results: The regularity of neoglottal vibration and the degree of neoglottal closure were significantly (P<.01) better in patients who had undergone the procedure than in those who had not. These effects on neoglottal vibration induced easier phonation. Conclusions: Cricopharyngeal myotomy was useful for avoiding reconstructed esophageal spasm, and tracheal cartilaginous implantation was effective for maintaining a wide subneoglottal space. This combination of procedures is useful for obtaining optimal vibration of the neoglottis in tracheoesophageal shunt and esophageal speakers.

17歳男,声帯隆起が消失し声門の開閉運動がなくなった食道瘻を伴う重度喉頭外傷例を経験した.本症例では,枠組みは破壊され内腔は肉芽組織で充満していたため,まず枠組みの再建をtrough methodで行い,更に前方開大術を追加した.内腔は粘膜移植で形成したが,声門は仮声帯のみで形成されたため,CO2レーザーによる声門の蒸散・拡大を段階的に行った.仮声帯粘膜は声帯粘膜より柔軟であり吸気時に声門に嵌頓し呼吸困難の原因となることが分かり,この部位を蒸散,瘢痕化することにより呼吸道としての機能を確保した.初診より6年後に気切孔を閉鎖し得た

声門下・気管狭窄の3症例(10歳女児,74歳男,56歳男)に対し,耳介複合弁による枠組みの再建を行い良好な結果を得た.本法は,複合弁をいったん喉頭気管溝の横の皮下に埋め込むことで確実な生着が得られ,また,内腔側の皮膚を有するため頸部の局所皮弁の必要がない点で有用と考えられた

声帯隆起が消失し声門の開閉運動がなくなった食道瘻を伴う重度喉頭外傷例を経験し、その治療上の留意点について考察したo本症例では、枠組みは破壊され内腔は肉芽組織で充満していたため、まず枠組みの再建をtrough methodで行い、さらに前方開大術を追加した。内腔は粘膜移植で形成したが、声門は仮声帯のみで形成されたため、 CO2レーザーによる声門の蒸散・拡大を段階的に行った。仮声帯粘膜は声帯粘膜より柔軟であり吸気時に声門に嵌頓し呼吸困難の原因となることが分かり、この部位を蒸散、瘢痕化することにより呼吸道としての機能を確保した。結果、初診より6年後に気切孔を閉鎖し得た。このような重度の喉頭外傷例では、まず枠組みを整復すること、次に声門の物性をよく見極めた上でその拡大法を選択することが気切孔閉鎖までもっていく上で重要と考えられた。

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.

A case of a long-standing foreign body in extrapharyngeal space is reported. A 61-year-old male experienced pharyngalgia after eating a sea bream. The pharyngalgia disappeared after 3 days. Six months later, he visited our hospital complaining of hoarseness, pharyngalgia and dyspnea. On laryngeal fiberscopy, we observed paralysis of the left vocal cord and edema of the left arytenoid and the left side of the epiglottis, but we found no foreign body. A cervical soft X-ray film revealed the foreign body in extrapharyngeal space. After we mitigated inflammation by using methylpredonisolone and antibiotics and identified the position of the foreign body by CT scan, we removed it by laryngomicro surgery. It was a fish-bone measuring 20 mm in length. Vocal cord paralysis disappeaed several days later.

A case of intramuscular hemangioma in the masseter muscle was reported. The patient was a 59-year-old female who complained of a left buccal tumor. The tumor was suspected to be an intramuscular hemangioma in the masseter muscle on the basis of MRI, CT and ultrasonography. The hemangioma was completely removed through an external incision. Pathological examination revealed it to be an arteriovenous hemangioma. The diagnosis and surgical treatment of intramuscular hemangioma in the masseter muscle were discussed.

Myoepithelioma is a rare lesion which has been reported mainly in the salivary glands. In the nasal cavity and paranasal sinuses, its occurrence is exceedingly rare and, to our knowledge, only 5 cases have been reported. We recently treated a 31-year-old female with myoepithelioma of the ethmoid sinus who presented with swallowing disturbance because of a rapidly expanding choanal polyp. We performed a Caldwell-Luc operation and found the tumor expanding into the ethmoid sinus. For diagnosis, immunohistochemical examination was effective in addition to H-E staining.