化学放射線療法と頸部郭清術後に重度の嚥下障害を呈した下咽頭癌の1例

A case of hypopharyngeal cancer with severe dysphagia following chemoradiation therapy and neck dissection

　化学放射線療法と頸部郭清術により重度の嚥下障害を呈した下咽頭癌例に嚥下訓練を施行したので，経過を報告し，改善を認めた舌根部の後退運動と食道入口部の通過について検討する．症例は53歳男性，下咽頭癌（T3N3M0）に対し，化学放射線療法が施行された．下咽頭部の腫瘍は消失したが頸部リンパ節病変は残存しており，根治的頸部郭清術，大胸筋皮弁再建術，神経移植による舌下神経再建術が施行された．摂食訓練と基礎的嚥下訓練を行い，舌根部の後退運動と食道入口部の通過に改善を認めた．手術65日後の標準ディサースリア検査で舌の運動範囲が改善し，舌下神経麻痺の改善も認めた．本例に舌下神経再建術が施行されたが，症状の改善時期が2か月と早い点，手術2年後に左舌の萎縮を認めた点より，舌根部の後退運動と食道入口部の通過の改善は，舌の訓練が効果的であった可能性が考えられた．舌下神経再建例に対し，術後早期のリハビリテーション介入の必要性が示唆された．

　We report a case of hypopharyngeal cancer with severe dysphagia following chemoradiation therapy and neck dissection and consider the effects on backward movement of the tongue base and opening of the upper esophageal sphincter. The case was a 53-year-old male with hypopharyngeal cancer(T3N3M0). Although the hypopharyngeal tumor disappeared following chemoradiation therapy, it persisted in the cervical lymph nodes. We performed radical neck dissection, reconstructive surgery using pectoralis major myocutaneous flap, and hypoglossal nerve reconstruction. Moreover, we conducted direct and indirect therapy for dysphagia postoperatively. The patient showed an improvement in backward movement of the tongue base and opening of the upper esophageal sphincter. Hypoglossal nerve paralysis showed an improvement on the assessment of motor speech for dysarthria at postoperative day 65. The effect of hypoglossal nerve reconstruction was apparent from postoperative month 2. His tongue muscles showed atrophy at postoperative year 2. In conclusion, tongue exercises were considered effective in improving backward movement of the tongue base and opening of the upper esophageal sphincter. Thus, the importance of performing tongue exercises in cases of hypoglossal nerve reconstruction was indicated.