This paper presents an extremely rare case of synovial sarcoma arising from the maxillary sinus, which resulted in a clinically complete response to chemotherapy. Synovial sarcoma is a rare soft tissue malignant tumor, most commonly affecting the extremities. While ~10% occur in the head and neck region, synovial sarcoma of the sinonasal tract is extremely rare, with only 11 cases having been reported previously. As with other sarcomas, the standard treatment is complete resection while allowing for a safe margin, but this is often difficult in the head and neck area due to the complicated anatomy there. This makes the treatment of head and neck sarcoma challenging and leads to the need for a multimodal approach in advanced cases. However, the exact efficacy of chemotherapy is not well understood. In this report, we present a case of unresectable maxillary sinus synovial sarcoma that was successfully treated by chemotherapy followed by radiation therapy. A 53-year-old Japanese man was referred to our hospital with a history of left nose obstruction over the previous couple of years. Computed tomography/magnetic resonance imaging revealed a tumor arising from the maxillary sinus that extended to adjacent tissues. A biopsy was performed, and the tumor was diagnosed as synovial sarcoma. Since the tumor was unresectable, neoadjuvant chemotherapy was administered. The response was excellent, and the tumor became undetectable under endoscopy and radiological imaging. This provided us with a clinical evaluation of “complete response”. The treatment was concluded with definitive radiotherapy and two more cycles of adjuvant chemotherapy. The patient remains free of disease 12 months after treatment. Synovial sarcoma of the head and neck is a rare entity; complete resection is the treatment of choice but (neo)adjuvant chemotherapy can be considered in unresectable cases, as we show here in the present case.

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Postoperative saliva leakage associated with wound dehiscence is one of the serious postoperative complications of major head and neck oncological surgery. Usually, a pharyngocutaneous fistula has to be formed for appropriate drainage of the infectious saliva to protect cervical vital structures, including the carotid artery. After the microvascular circulation around the fistula becomes stable, the fistula can be closed safely using a hinge flap and local rotation or a free island flap. Conventionally, the pharyngocutaneous fistula is maintained by plugging it with ointment gauze and covering it tightly with dry gauze and adhesive tapes ; the tracheal stoma has to be managed with a cuffed cannula to prevent aspiration of saliva. However, this conventional method is associated with heavy distress to the patient, such as skin damage and pain due to frequent replacement of gauze and tapes, and increased cough and sputum induced by the 日耳鼻 松居・他＝咽頭皮膚瘻のパウチ管理 125-277 tracheal cannula insertion. In recent years, various alternative methods have been reported for mitigating the patients' burden associated with fistula management. However, these methods cannot solve the pharyngocutaneous fistula-specific problems which are attributed to the three-dimensional structure and mobility of the neck. Therefore, we developed a new management method for fistula using a combination of a urine collection bag or a stoma pouch and a clay-like skin protecting agent, which enabled us to flexibly manage various cases by adjusting the attachment-plate area of the pouch and shaping a wall with clay-like skin protectant. As a result, we could reduce the frequency of fistula coverage replacement from daily to once every 3 to 4 days, which resulted in decreased skin damage and pain, and avoidance of tracheal cannulation. Furthermore, the daily material cost was also greatly reduced. In conclusion, we believe that this new method can overcome the disadvantages of the conventional method, reduce the burden on the patients, and reduce the cost, yielding medical economic benefit. In addition, the cooperation of the patients themselves and a certified nurse familiar with handling the pouch materials appears to be helpful for successful management.