ORL is one medical area where remarkable changes have been observed, both in the diseases and treatments concerned. Although ORL had its origins in emergency surgery, the modern otolary-ngologist handles more chronic surgical cases and many neurological cases as well. The major agents of these changes are the active application of microsurgical techniques and electronic technology, in addition to the advent of antibiotics.
In order to estabish the reputation of the practice of ORL as a progressive field which keeps up with modern developments, the following approaches are suggested:
1) Increasing the time devoted to counselling patients; this will require a reduction in the number of patients seen per day.
2) Performing more clinical tests; technical assistants as well as laboratory facilities are needed.
3) Reevaluating minor-surgical and non-surgical manoeuvers; more efficient and less time-consuming methods must be utilized.
4) Broadening indications for surgery; assistants and facilities for both surgery and recovery needed.
5) Gaining more active access to rehabilitation in ORL; interactive as well as cooperative relations with local personnel and facilities should be facilitated.
Modern ORL specialists may concentrate on one or two of the above-mentioned areas. Two other recommendations for the modernization of ORL are the group practice and the open-system hospital. Alternatively, a system of close cooperation between specialists and the center hospital is advocated.

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A questionnaire was distributed to otorhinolaryngologists for the purpose of studying the present status of so-called general treatments, and the following results were obtained. The general treatments most widely performed at outpatient-clinic were local treatment with applicator to external and/or middle ear (89.2%), inflation of eustachian tube with catheterization (89.0%), nasal spray (87.3%), nasal suction (85.3%), nasal nebulizer (84.3%), direct application of medicated solutiong to the pharyngeal area (76.3%), laryngeal nebulizer (72.8%), gargling (67.9%) etc.
In this investigation success rates were reported for such treatments as incision of peritonsillar abscess (92.6%), catheterization (89.9%), intranasal gauze-tamponade for stopping nasal bleeding (89.0%), paracentesis (86.0%), tympanotomy (81.8%), nasal suction (77.5%), nasal spray (71.0%) and laryngeal nebulizer (70.0%).

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The relative volume of local treatments in the daily practice of the otorhinolaryngologic specialists, compared to other medical specialities, is tremendously heavy.
The aim of this survey is to analyse the importance of the local treatments with regard to their original characteristics from various points of view. Questionnaires were sent to the members of the Kanagawa region of the Otorhinolaryngological Society of Japan to survey what frequency and what type of treatments among 103 different types of local treatments they had performed in their daily practice in a week between January 13th and 19th, 1980 as well as in the last 3 months, and to elicit their answers as to what types of local treatments they considered as the highly specialized ones. The results were as follows:
Twenty-nine types of the local treatments were performed more than once in that week, and 45 were performed rarely but always when patients necessitated these treatments.
Sixty-one types were recognized as the highly specialized ones in 70% of the answerers, but 16 were thought as unspecialized in the majority of the answerers.

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1. The problems of visual examination in ENT practice.
The otolaryngological region consists mainly of deep narrow slits, canals, and cavities, though it is reached from outside of the body. On the other hand, the visual acuity of the surgeon for near vision becomes increasingly poorer with age. According to Ishihara, observation with the naked eye at distances less than 50cm, becomes fairly difficult for Japanese with normal vision. This means there is a need of somesort of magnification for observation in ENT practice for the majority of otolaryngologists.
2. Present status of inspection in ENT local treatment.
(1) Ear: For detailed observation and local treatment of the ear drum and middle ear, 6 to 16 times magnification is necessary. This problem is being solved by the introduction of binocular microscope, endoscope or monocular aural microscope. According to a recent survey, the coefficient of utlization of the binocular microscope is 53.8% in university doctors, and 12.5% in office practitioners in Japan.
(2) Nose: The introduction of flexible fiberscopes enabled detailed observation of otherwise inaccessible structures. This is most helpful for local treatment as well as diagnosis in these regions. The utlization of this instrument still seems to be low in office practice.
(3) Nasopharynx: Flexible or rigid type endoscopes can be effectively employed for observation and local treatment.
(4) Larynx and hypopharynx: Observation of these areas has been made easier by the introduction of the pernasal flexible fiberscope and peroral rigid type endoscope. The utilization of laryngeal endoscopes for practice was 72.3% in university hospitals and 35.1% in office practice.
(5) Therapeutic endoscopes: It is considered that development of therapeutic endoscopes will make it possible to enlarge the limits of ENT local treatment in biopsy, removal of pathological tissue, administration of therapeutic agents to target cavities,. and injection. However, these instruments still leave room for further improvement.
3. Conclusion
The present status and problems of inspective measures with regard to ENT local treatment is surveyed. For safe, reliable and easy local treatment promoting the advancement of medicine, the introduction of magnification, and endoscope is considered to be indispensable to improving present status of ENT local treatment. However, further effort is necessary to match these measures to every type of current ENT practice, and more improvement of inspection methods is advisable.

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In some parts of Tokyo and whole Aichi prefecture, we sent out a questionnaire with the recovery of about 60%. The answers were analyzed to determine how routine practice in ORL should be at present and in the future. Problems obtained from the survey were summarized as follows:
(1) The number of outpatients is too large.
(2) The routine treatments in ORL should be reviewed.
(3) New medical techniques must be adopted.
(4) The open-service-system of hospitals must be promoted.
(5) Facilities for rehabilitation should be always available to meet the needs of patients.
From the analysis of the survey, the authors tried to form the more desirable model of ORL practice. The purpose of this study was to analyze the present situation of ORL for diagnosis, therapy and rehabilitation and to recognize problems at present and in the future.

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The treatment of external and middle ear diseases was studied from the bacteriological standpoint.
The Gramm (+) bacilli, the most common cause of the infection, were found most sensitive to the synthetic penicillin and cephalosporin groups. The Pseudomonas and Proteus group also showed sensitivity to synthetic penicillin, aminoglycoside and naridixic acid. However we must recognize changes in the causative bacilli as well as their antibiotic sensitivities duaring the course of the antibiotic treatment, and we have to select the proper antibiotic which is sensitive to the bacteria each time.
Drugs administred as ear drops with the tragus pressure maneuver do not enter the attic paces but might contact the round window membrane with the possibility of inner ear damage.

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1. Eustachian tube catheterization (E. T. C.) for diagnosis and treatment of middle ear dysfunction.
The catheterization of Eustachian tube could be used not only for diagnosis, but also for treatment of middle ear diseases. By the catheterization, we can get valuable information about the middle ear cavity and the tympanic membrane.
1) The drum gives clear picture of itself when it is raised. Whether or not the drum could be raised would also be checked.
2) Air bubbles could be easily detectable when the middle ear is inflated.
3) The condition of the tympanic fold and the other middle ear structures could be examined by the process of inflation.
The diagnostic significance of inflation during the act of swallowing is also stressed.
2. Tympanotomy tube.
In view of the recent increase of the middle ear disease with effusion, the study was done on its diagnosis and treatment. In the present study, the rationale of tympanotomy tube therapy, which was favorably approved by several authors, was critically checked.
The collapse of the ear drum is seemingly due to the negative pressure not only in the middle ear but also in the nasopharynx. As it is evident that myringotomy alone does not cure the atelectasis, first choice of the initial treatment in our clinic is catheterization. Then myringotomy followed with aspiration, and tympanotomy tube therapy are considered for persistent cases.

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Questionaries on rhinological treatments were sent to all ENT doctors in Hokkaido as well as to randomly selected ones in the rest of Japan. The frequencies of various treatments and their effects were analyzed. The most definite difference between the two regions was frequency and evaluation of nasal irrigation. 14 patients with paranasal sinusitis were radiologically examined before and after nasal irrigation and after antral lavage. Ciliary movements of the mucous membrane of the nose were microscopically observed while various solutions were perfused on the specimen. These fundamental experiments and bibliographical study suggested that nasal irrigation was a supportive therapy as one of cleansing methods. Nasal irrigation promotes the elimination of excess secretion and the recovery of ciliary activity. Indications and precautions of the method were considered.

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A questionnaire on the management of nasal hemorrhage was conducted in 511 otorhinolar-yngological clinicians. The common procedures to control the hemorrhage were the insertion of gauze in 67.5%, chemical cauterization in 44.4%, electrocauterization in 20.5%, the insertion of a Bellocq tampon in 11.0% and balloon catheterization in 2.7%. Although the balloon catheterization and electrocoagulation proved to be markedly effective, the incidence of practical application was low.
The scarification of the submucous perichondrium was employed in 17 subjects with incontrollable spontaneous eruptive hemorrhage, and the results were satisfactory.
In order to clarify the proper selection of hemostatic methods, the nasal hemorrhage was pathologically classified (Grade I-V) according to the difficulty of control.
For the hemostasis of incontrollable subjects, we pointed out a target in introducing new medical techniques.

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The ability of the nasal respiratory mucosa to clear themselves of accumulated foreign material and to provide an ever fresh and moist surface is essential to human health.
The purpose of the present study was to determine whether nasal clearance is affected by nasal spray with topical anesthetic and decongestant agents.
Nasal mucociliary flow rate was measured by saccharine technique.
Discoloration and shrinkage of the inferior turbinate was analysed using organ-reflectance spectrometry, and pathological change of the nasal mucosa was observed by scanning electron-microscope.
The excessive doses of topical anesthetic and vasocontrictor agents were found to cause functional and ultrastructial disturbences in the nasal mucosa.
A linear relationship was revealed among spectrometric value, coloriometric index, mucous flow rate and surface structural change in the mucous membrane of the nasal cavity.
On the basis of the results which have been thus obtained clinical evaluation of variable combination therapy with nasal spray was discussed briefly.

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The epithelial surface of human tonsillar crypt following topical spray or apply of an astringent was investigated.
A larger amount of non-epithelial cell in the micropole of the tonsillar crypt and detachment of the epithelia seemed to be observed, in the treated tonsil when compared with that of the untreated one.
There was no difference between commercial agent and physiological saline solution as regards clinical and bacteriological effectiveness of gargle therapy.
The functional significance of the tonsillar crypt and pathogenic flora was briefly discussed.

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I. A survey with questionaire.
Five-hundred and eleven ENT doctors responded to our questionaire. The most frequent office procedure was nebulizer (88%). Steroid and/or antibiotics were used most frequently. Many doctors believed that nebulizer was effective for acute laryngitis and post-surgical condition. Local application of medicines with the use of an applicator, a sprayer, an inhalator or a laryngeal syringe was less frequent. Intracordal injection of medicine was the least frequent.
II. Measurement of intra-tissue concentration of locally applied antibiotics.
Tobramycin concentration within the mucosa of canine vocal folds was measured. It was revealed that tobramycin applied on the mucosal surface was transported into the mucosa. Intracordal injection of tobramycin resulted in a very high intra-tissue concentration.

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