In order for achieving a permanent tracheo-esophageal shunt for the post operative vocal function, the following requirements should be satisfied. 1) technically easy and safe, 2) applicable to almost all cases, 3) one-stage operation, 4) leakage of saliva and/or fluid from the esophagus into the trachea is negligible, and 5) the obtained speech function should at least be equivalent or even exceeding the speech obtained by nonsurgical methods. A new surgical technique reported herein satisfies most of the requirements mentioned above. Techniques 1) Skin Incision and Tracheostomy: A U-shaped or I-shaped incision is made and a spindleshaped opening is made at the level of the third and fourth tacheal ring. An endotracheal tube for general anesthesia is inserted through this opening. 2) Laryngectomy: An attention should be paid in order not to separate the posterior wall of the trachea from the anterior wall of the esophagus. The larynx is removed juat above the first tracheal ring. If there is no suspicious growth to the subglottis, a removal just above the cricoid arch using a pair of angulated heavy scissors is preferrable. Otherwise, laryngectomy is performed in an ordinary fashion. 3) Creation of Tracheal Flap and Lower Half of the Tracheostoma: The anterior two thirds of the tracheal wall above the fourth ring is cut off, thus a tracheal flap, measuring 2.5 X 4 cm based inferioly, is obtained. The remainder of the tracheal and the cricoid cartilages on both sides is carefully removed subperichondrally using a pair of small scissors. The lower half of tracheostoma is formed after this procedure. 4) Creation of Side-to-Side Anastomosis and Closure of the Hypopharynx: A 7mm midline vertical incision is made starting 5 mm below the superior margin of the flap to reach the esophageal lumen. A single layer of mucosal inter- rupted 4-0 catgut sutures is used to create a sideto-side anastomosis between the incised margins of the tracheal flap and the esophagus. Closure of the hypopharynx is done in an ordinary fashion. 5) Creation of the Tracheo-Esophageal Shunt: A 5-0 Nelation catheter is inserted through this anastomosed opening into the esophagus before completing the T-E shunt. A single layer of submucosal interrupted 4-0 catgut sutures is made to approximate the both lateral margins of the tracheal flap starting from above or below. Thus a 3 cm mucosal tunnel connecting the esophagus and the tracheostoma is constructed. 6) Creation of Upper Half of the Tracheostoma and Closure of the Skin Incision: After suction drains are inserted on each side and fixed on the chest wall, the upper half of the tracheostoma, the center of which is formed by lower end of the mucosal tunnel, is created starting from midline using 3-0 nylon. After 12-20 days, the inserted Nelation catheter is removed. Voice can be produced after the removal of the Nllation catheter by closing the stoma with a finger and giving an expiratory effort. Results Eleven patients so far underwent this procedure and all of them were able to speak 12-52
It is of great importance to know the incidence of viral infection on Bell's palsy and to establish an early differential diagnosis, not only for elucidating the causes of Bell's palsy but also for deciding the proper treatment, in 11 research facilities located throughout Japan were studied on 257 cases diagnosed as Bell's palsy and compared with the result on a healthy control group and a Ramsay Hunt's syndrome group . Antibody titers to eight viruses: varicella-zoster virus, herpes simplex virus, influenza A and B virus, mumps virus, adenovirus (all the above by complement-fixing reaction), rubella virus, and Japanese encephalitis virus (the last two by hemoagglutination inhibitation test). Viral infection was judged positive in such a case that titer differerence between the acuteand convalescent-phase specimens was four times or more. For the Ramsay Hunt's syndrome group (47 cases), all except the extremely mild cases exhibited significant increase in the antibody titer to varicella-zoster virus, re-confirming that V-Z virus caused Ramsay Hunt's syndrome. Out of the 257 cases of Bell's palsy, 94 cases (37%) showed significant increase in one or more of the types of virus by repetitive examination. Forty-five cases (18%) in the patients showed a significant rise in V-Z antibody titers. There were 14 cases (5%) for which herpes simplex virus can be the cause of paralysis. The fact that the incidence of mixed infection with influenza A virus, influenza B virus, or adenovirus in patients of zoster sine herpete (27%) was markedly greater than in the case of Ramsay Hunt's syndrome (4%) may indicate that owing to mixed infection with these viruses, lowvirulence varicellazoster virus may interact to generate facial paralysis
A drawback in the diagnosis of viral infection in Bell's palsy is that when the conclusive diagnosis is made, the course of the treatment has already been decided and the diagnosis is thus of little clinical help. In general, at the first viral infection, the antibody which appears earliest is the IgM antibody, normally appearing in the serum two to three days after infection, reaching its maximum several days later and disappearing in the following several weeks. Replacing the IgM antibody, the IgG antibody appears ten or more days after infection and is maintained for se- veral years. Thus, in the event that virus antibodies are found at the initial examination, if it is immediately confirmed that the antibody is the IgM antibody, the early diagnosis of viral infection becomes possible. In order to determine the presence of the IgM antibody to viral infection, a susceptibility test to 2-mercapto-ethanol was employed. An examination was conducted of the sera obtained from 11 cases of Ramsay Hunt's syndrome and 22 cases of Bell's palsy showing V-Z virus antibody titers of 8-fold and greater. In all the cases of Ramsay Hunt's syndrome and 20 cases of Bell's palsy, IgM antibody constituted all or the great majority of the antibodies found. In those cases in which antibody titers are revealed at the initial examinaton, it is possible to shorten the time required for the diagnosis of viral infection by using a procedure to prove that the IgM antibody is confirmed.
Parotid tumors obtained at surgery were electronmicroscopically observed. Specimens were fixed with 4% glutaraldehyde and 2% osmium tetroxide, buffered with PH= 7. 2 cacodylate solutions. After dehydration through ethanol series, these were embedded in Epon 812 and cut in ultra-thin sections. These sections were stained with uranlyl acetate and lead citrate. The results were as follows; 1) Pleomorphic adenoma consisted of tubular portion, solid portion and others. Tumor cells of tubular portion were composed of bssal cell, spinosum cell and columnar cell. In the cytoplasma of columnar cells fine filaments increased markedly in numbea. In tumor cells of solid portion intracytoplasmic filaments and other organelles were unremarkable. Numerous myoepithelial-like cells were found in chondroid and myxoid regions. 2) Histological observations on adenoid cystic carcinoma were characterized by cystic spaces. These spaces were coated by undulatedly thickened basement membrane and filled with fine filaments and amorphous substances. Tumor cells and myoepithelial-like cells were observed in the vicinity of the cystic spaces. Some intercellular canaliculi were found. 3) Mucoepidermoid tumor consisted of goblet-like mucous cells, epidermoid cells and basal cells. Perichromatin in nuclei and tonofilament in the cytoplasma of basal cells were prominent. 4) Adenolymphoma consisted of epithelial and lymphoid components.. Epithelial cells contained numersus mitochondria. These cells were similar with oncocytes. Amorphous materials and lymphocytes were found in the cyst. Small lymphoocytes in lymphoid portions increased markedly in number. It is not determine at present whether these lymphocytes are neoplastic or not.
The authors performed the air caloric test using the air caloric stimulator NCA-100 (ICS) under various conditions, and determined the optimum conditions of 24°C, 50°C, 60 seconds and 6 litters/min. for air irrigation without causing discomfort to patients during a stimulation. This air caloric test was applied to 15 normal subjects, and was evaluated by measuring nystagmic responses with respect to duration, total number of beats and maximum eye-speed of the slow-nystagmus-phase. We found the duration of the air caloric nystagmus to be one of the most reliable parameters. No significant differences were noted between air caloric and water caloric responses (30°C, 44°C, 50 ml., 20 sec.). Considering our data obtinaed from normal subjects, the air caloric test is reliable, convenient and applicable. However, for ., patient with inflammatory middle ear paradoxical caloric response was recorded by air calorization.